Lines, Chemo, Cancer, Oh My! - PowerPoint Presentation

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Lines, Chemo, Cancer, Oh My! General Nursing Care of the Pediatric Oncology Patient

Lindsey Zaremba BSN, RN, CPN, CPHON

Shelly Wilke BSN, RN, CPHON

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Objectives

Identify the three common types of pediatric cancers.Describe the different treatment modalities for treating pediatric cancer.Describe nursing interventions in oncologic emergencies.

Recognize symptoms of pediatric oncologic emergencies.

Describe nursing interventions that can impact the psychosocial care of a pediatric oncology patient and family.

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What is Cancer?

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Cancer is rapidly dividing abnormal cells.In the United States in 2017, an estimated 10,270 new cases of cancer will be diagnosed among children from birth to 14 years versus 1.5 million for adults. Approximately 1,190 children are expected to die from the disease.Cancer is leading

cause of death from disease among children

.

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History

1939- First pediatric cancer unit in the U.S.1940-Discovery that folic acid antagonist produced temporary remission will ALL 1950s-1960s-Single agent chemotherapy1970-Combination chemotherapy2000-Children’s Oncology Group (COG) formed.

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Types of Cancer

LeukemiaALLT-cell ALLAMLLymphomaHodgkins

Non

Hodgkins

Brain and spinal cord

tumors

Astrocytoma

Ependymoma

M

edulloblastoma

Solid Tumors

Neuroblastoma

Wilms

Tumor

Rhabdomyosarcoma

Bone

Tumors

Osteosarcoma

Ewings

Sarcoma

Retinoblastoma

Germ Cell Tumors

Hepatoblastoma

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Genetic ConditionsDown SyndromeShwachman DiamondLi-FraumeniBeckwith-WiedemannNeurofibromatosis

Prior radiation

Previous Chemotherapy (alkylating agents,

epipodophyllotoxins

)

Risk Factors

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Leukemia

Acute Lymphoblastic Leukemia (ALL)Acute Myeloid Leukemia (AML)ALL accounts for 75% of all childhood leukemia'sDX: Lumbar Puncture, CBC, Bone MarrowTX: Chemo, Stem Cell Transplant

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ALL

Prognostic factorsAgeWBC countMinimal Residual Disease at Day 29 (MRD)TreatmentInduction

Post Induction

Maintenance

Boys= Approximately 3 years

Girls=Approximately 2 years

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Solid Tumors

Can affect any part of the bodySymptoms are generally related to the location of the tumorMultimodal therapyChemotherapy

Surgery

Radiation

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Brain Tumors

CNS tumors are the most common solid tumor in children (approximately 20%)Most pediatric brain tumors are primary tumorsThe diagnosis of the type of brain tumor is based on location of tumor and types of cells in the tumorTX: Surgery, Chemo, Radiation

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Treatment Modalities

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Chemotherapy

Drugs that are used to treat cancerDesigned to slow or stop the growth of cancer cellsRegimens are disease specific based on researchCan be used for cure, control of cancer or to ease cancer symptoms

Administration safety

Checked and double checked by multiple professionals prior to administration

Administered by trained nursing and medical staff

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History of chemo

Roots of chemotherapy trace back to chemical weapons used in World War 1Research on the effects of mustard gas led to the development of nitrogen mustardFollowed by antifolates (MTX) 6mp and vincristine

Discovery that cancer could be treated with drugs

Combination chemotherapy

Use of multiple different drugs to attack cancer cells at different stages and in different ways

Other treatment modalities

Use of chemotherapy in conjunction with other treatments to cure cancer

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Routes

Orally (PO)Intravenously (IV)IntramuscularSubcutaneously (SC) Intrathecally (IT)IntraoperativelyIntra-

ommaya

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Clinical trials

60% of children are enrolled in a clinical trial at diagnosis versus Adults is 1%.Research studies that test new treatments to see how well they workNew drugsNew combinations of drugsNew treatment modalities

Designed to find better ways to treat cancer

Participation correlate to survival rates

Phase

I

Demonstrate that people can safely use new drug or treatment

Phase

II

Demonstrate that the drug or treatment works against specific cancers

Phase

III

Compare the drug or treatment against the current standard of care to see if it is better

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Radiation therapy

High energy radiation to shrink tumors and kill cancer cellsRadiation doses for cancers are measured in units called a gray (Gy)Maximum doses for specific sites

Can treat other sites if maximum dose is reached in one site

Types

External beam radiation

Proton therapy

Brachytherapy

Nursing Care:

Hypoxic cells are more resistant to radiation. Check Hemoglobin prior to radiation.

Do not remove markings. No lotions.

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Surgery

Used in cancer treatmentBiopsyDetermine type of tumorResectionMay be partial or total

Goal is to remove entire tumor with margins of normal tissue to minimize chances of recurrence

Limb salvage or limb sparing

Used in supportive treatment

Placement of central line

Placement of

shunts

Procedures

Lumbar Puncture

Bone Marrow Biopsy/Aspirate

Nursing Care:

Lumbar

Puncture and Bone marrow aspirates and biopsy-Nursing care: Remove band aid or pressure dressing in 24 hours

.

Assess blood counts prior to surgery.

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Chemotherapy administration

Association of Pediatric Hematology Oncology Chemotherapy/Biotherapy ProgramProvider status due for renewal every two years. Hospital may require additional check offs.Provider wears personal protective equipment that includes a non-permeable chemo gown and double gloves.

If given intravenous, must have blood return prior to, during, and after.

Chemo mats used to prevent exposure.

Flushes given via closed system

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Chemo precautions

Staff and family members must wear gloves at least 48 hours post chemotherapy administration.For crushing of pills, send to pharmacy to be done under the hood. Know your institutions policy on disposing of waste correctly.When flushing toilets, may cover with a disposable pad.

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Central line

TypesPACExternal Central lineHickmanCookBroviac

PICC line

Pain per protocol for PAC accessing.

Care of the Central line

Weekly and as needed dressing changes

While in hospital, biweekly cap changes

15/15

cleaning of site with alcohol

prior to connecting or disconnecting from a central

line

Considered by these patients and families as their lifeline

Infections are life threatening

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Labs and interpreting them

“Counts”“Count dependent”“What are my counts?”

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Neutropenia

Condition caused by a decreased number of neutrophils in the bloodstreamNeutrophils=bacteria fightersCommon side effect of cancer treatments (chemotherapy and radiation)ANC= WBC x (segs+bands

) divided by

100

Typical Nadir 7-10 days with a 14-21 day count recovery.

Classifications of neutropenia

Mild - ANC<1500

Moderate - ANC<1000

Severe - ANC<

500

Neutropenic Precautions

NO RECTAL TEMPERATURES

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Oncologic emergencies

Life threatening events occurring At cancer diagnosisDuring treatmentAt recurrenceAt end of life

Electrolyte imbalances

TLS

SIADH

Fever

Sepsis

shock

Anaphylaxis

DIC

Typhlitis

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Electrolyte abnormalities

Tumor Lysis SyndromeConstellation of signs and symptoms that result from a massive destruction of cells that are released into the bloodstream and exceed the kidneys capacity to eliminate themHyperuricemia

Hyperkalemia

Hyperphosphatemia

Hypocalcaemia

SIADH

Increase in the release of anti-diuretic hormone (ADH) leading to an increase in water reabsorption by the kidneys which leads to

dilutional

hyponatremia

Decreased sodium

Decreased urinary output

Increase in weight without associated edema

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Fever

Defined by Hematology/Oncology at Texas Children’s Hospital as:Temperature of 100.4 or greater times 2 greater then 60 minutes apartTemperature of 101May progress quickly to sepsis/septic shock

Nursing interventions

Obtain blood cultures centrally and peripherally

Initiate antibiotics promptly (the goal is within 60 minutes)

Monitor closely

Communicate changes with medical team

Changes in nursing assessment

Changes in vital signs

Support the patient/family

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Anaphylaxis

Hypersensitivity reaction to foreign proteinAntibioticsBlood productsChemotherapySymptoms

Wheezing/dyspnea

Laryngeal edema/stridor

Erythema/flushing

Facial swelling

Anxiety/agitation

Treatment

Stop the infusion

Maintain airway

Oxygen

Notify provider

Epinephrine

Benadryl

H

ydrocortisone

Maintain calm

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DICAlteration in blood clotting mechanisms manifested byDecreased plateletsIncreased prothrombinDecreased fibrinogenNot a primary disease by a secondary clotting problem that occurs with another disease process

Typhlitis

Bacterial invasion of the cecum which leads to necrotizing colitis

Risk factors

High-dose chemotherapy

Severe/prolonged neutropenia

Acute leukemia induction

Infection

Mucositis

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Transfusions

Why are transfusions needed?

Disease

Side effect of treatment

Pre-procedure

When are transfusions needed?

General guidelines

Hgb

< 8

Plt

< 20K

How are transfusions given?

Hospital policy

Hospital

procedure

Avoid NSAIDs

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Psychosocial Care

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Patient Family education

Education should be a part of every visit (or admission)Safety

Medications

Lab results/implications

Contact information

Care of lines

Precautions/isolation at home

Environment

Food

Visitors

Disease process and treatment

Medical Professional Think New Family Need:  Initial Hospital Stay

What Parents reported was Taught

What parents WANTED

Diagnosis

Fever

Length of hospitalization and possible d/c

Fever

Medications and side effects

Likelihood of hospital readmission

Prognosis

Mood Swings for steroids

Why patient is receving a transfusion

Side Effects

Symptoms to watch for

Timeframe for neutropenia

Who/How to call

Blood Cells

Implications of neutropenia once d/c.  (need stay home etc)

When/Why call

Transfusions

Ways to encourage child to eat

Clinical trials

Hand Washing

Chemotherapy precautions for family members

Manage Medications

Hygiene and oral care

Activity restrictions (swimming...)

Central Line Care

How To Take Temperature

Duration of Treatment and need for long term follow up

Care of Child at Home

Care of Central Line

Support Groups through social media and in person

Supportive Care

Sings of CL infection

 

Health Team Members

Not to give over the counter meds

 

Preventing Infection

Infertility

 

Blood Counts

Roadmap for treatment

 

Follow Up Appointments

When patient wear mask

 

Fertility

Nutrition

 

School

Prepare fo rhome discharge

 

 

Info for siblings

 

Medical Professional Think New Family Need: Education Prior to Intial Hospital D/c

What Parents reported was Taught Before D/C

What parents WANTED

Diagnosis

Emergency Phone #

How to give child oral meds

Fever

Fever

What to do if child vomits after oral med

Prognosis

Need to go to hospital if fever develops

Clinic Routine

Side Effects

Medications - schedule, dosing,…

Needle size for port access

Who/How to call

How to administer injections

Precautions for Sibs

When/Why call

Not to give over the counter meds

Precautions for visitors at home

Clinical trials

Neutropenic Precautions

Diet precautions (wash fruit really well means?)

Manage Medications

Thrombocytopenic precautions

Support Groups through social media and in person

Central Line Care

Care of Central Line

 

Care of Child at Home

Hygiene

 

Supportive Care

Hand washing

 

Health Team Members

Oral care and diet if mucositis develops

 

Preventing Infection

Nutrition and diet precautions

 

Blood Counts

Minimize sun exposure

 

Follow Up Appointments

Call with any questions

 

Fertility

expect unplanned admissions

 

School

Frequency of clinic visits

 

 

Info for siblings

 

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It’s the little things….

Why is it different?Frequent visits and hospital stays

Knowledge level of parents

Loss of control

In the back of their mind, understand the severity of the illness and their situation

ICU

Relapse

Death

What can we do?

What makes the patients visit or stay “less bad”

Involve parents in care to the degree of their comfort

Sit down with

pt

/family to make a plan for the visit/day

Respect the routines of the patient and family

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Adolescent young adults (AYA)

Defined as ages 15-39Approximately 8x higher incidence then children <age 15 to be diagnosed

Number 1 cause of death by disease in this age group

Challenges

Access to care

Delayed diagnosis

Wide developmental variation

Low participation in clinical trials

“No man’s land” between pediatric and adult providers

Limited age-appropriate psychosocial/support services

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campBenefits of CampOffer a time of normalcy for kids suffering from significant emotional and physical challenges

Focus on what the kids can do

Build self confidence

Reduce perception of isolation

Develop support network of others who are facing similar challenges

Offer a time of respite for families

Parents able to focus on the rest of the family or on their partner

Focus on siblings

May be invited to be part of camp

May be able to have some special times with parents

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“I think the week helped her (the camper) see how strong she can be and that she isn’t the only one that is “different””“The campers inspire me each and every year. They show us how to be the most we can be. They fight and teach and inspire without even trying”

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Palliative Care/difficult conversations

Palliative Care focuses on prevention and relief of suffering, regardless of the stage of disease, and comprehensively addresses the physical, psychosocial, or spiritual needs of the child and family

Begins at diagnosis of life-threatening or life limiting illness

Should be addressed throughout care of the patient

Transitions to End of Life care

End of life care-initial issues

Resuscitative efforts

Supportive care measures

Fatigue

Medications

Nutrition and fluids

Lab tests

VS monitoring

Blood product support

Location of care

Transition process for healthcare providers

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Case Study

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Story of Lucy

Lucy is a 16 year old who has a one month history of leg pain. She was seen by her pediatrician and diagnosed with “growing pains.” Lucy has been sleeping a lot and has had a low grade temp of 100.2 off and on for a week. Her mother decides to take her to the doctors again. What tests do you anticipate the MD ordering?

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The MD ordered a CBC and sent Lucy and her mother home. About 2 hours later, Lucy’s mother received a call that she needed to take Lucy to the emergency room immediately. Lucy’s CBC results:Hemoglobin-6.2Platelets-25

Blasts-15%

ANC-600

1) What interventions do you anticipate happening at the ED?

2) What do you suspect Lucy’s diagnosis is?

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Lucy is given a blood and platelet transfusion. She is then taken to the OR and had a lumbar puncture and bone marrow biopsy/aspiration. Without knowing the BMA results, what type of treatment protocol would you expect Lucy to be treated on?Standard riskIntermediate risk

High risk

Answer: High Risk (age 16)

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Lucy is admitted to the hospital and receives chemotherapy. On the second day she complains of severe leg cramps. A CHEM 10 is ordered and her calcium was noted to be 6.0. What is Lucy showing signs of?Typhlitis

Tumor Lysis Syndrome

Anaphylaxis

SIADH

Answer: Tumor Lysis Syndrome

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Lucy is later discharged from the hospital and follows up in the outpatient clinic. Her Day 29 bone marrow biopsy was negative for MRD. She goes through treatment with minimal complications and is now a counselor at a camp for his with cancer.

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References

1

) Anderson, J.,

Krailo

, M., O’Leary, M.,

Reaman

, G. (2008).

Progress in Childhood Cancer: 50 Years of Research Collaboration, A Report from

the Children's

Oncology Group.

Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2702720/pdf/nihms73614.pdf

2) Bryant, R.,

Calson

, C., Hooke, M., Kline, N., Nixon, C. (Eds.). (2014)

Essentials of pediatric oncology nursing

. (4

th

ed.). Chicago, IL: Association of Pediatric Oncology Nursing

3) Cancer

Incidence

(2017) Retrieved from

http://

www.curetoday.com/tumor/childhood/treatment/cdr0000062872

.

4) Childhood

cancers

(2017) Retrieved from https://www.cancer.gov/types/childhood-cancers

.

5) Cancer Statistics (2017) Retrieved from h

ttps://www.cancer.gov/about-cancer/understanding/statistics

.

6) Childhood cancers research

(2016) Retrieved from

https://

www.cancer.gov/research/areas/childhood

.