what is Leukemia?
It is a broad term given to a group of malignant diseases of the bone marrow and lymphatic system.
It is cancer of blood forming tissue
what are the two types of Leukemia?
the two types of Leukemia are:
Acute lymphoid leukemia (ALL) (80% cure rate)
It can also be called acute lymphatic, lymphocytic, lymphoblastic, or lymphoblastoid leukemia
Acute non-lymphoid (myelogenous) leukemia (ANLL or AML) (45% cure rate)
It can also be called granulocytic, monocytic, myelogenous, monoblastic and monomyeloblastic
what is the pathphysiology of leukemia
unrestricted proliferation of immature WBC which can infiltrate and replace any body tissue specially high vascular organ tissue such as liver and spleen. WBC demonstrate same neoplasmic characteristics as solid cancer.
is leukemia overproduction of mature or immature WBC and which ones are higher
Leukemia is overproduction of immature WBC but regular WBC are low
How does immature WBC in leukemia destroys tissues?
the immature WBC do not distroy the tissues deliberately but the cellular destruction occurs by infiltration and when they compete for metabolic elements.
what are the consequences of cell destruction by immature WBC infiltration?
there are three consequences:
what is the consequence of bone marrow invasion in leukemia?
It gradually causes weakening of the bone and may cause fracture
what is the consequence of periosteum invasion in leukemia
Invasion of the periosteum, increases pressure and increases pain
what is the consequences of spleen, liver, and lymph node invasion in leukemia
Spleen, liver and lymph glands are infiltrated and this cause hepatosplenomegaly and eventual fibrosis
what are the treatments for Leukemia
2:CNS prophylactic therapy
4:Maintenance- daily and weekly administration of meds for 2 years.
6:Hematopoietic Stem Cell transplantation (HSCT) (BMT)
what is the prognosis for leukemia
depends on several factors:
1: onset of age: kids between 2-9 do better than before 2 and after 10
2: Gender: girls do better than boys
3: initial WBC count: normal or low do better
4: DNA index: children with DNA index greater than 1.16 and a translocation of chromosome 4 and 10 do better.
what are the late effects of Leukemia treatment
Almost every antineoplastic drug, including radiation, is responsible for negative organ effect (all organs are affected).
Secondary malignancy- lymphoma
Children with cranial radiation before 5 are susceptible to brain tumors.
Anthracycline causes cardiomyopathy
Intrathecal chemo causes cognitive delays
what are some of the nursing care for leukemia?
Administer chemo safely
Teach parents all about leukemia
Teach parents all about the S & S of sepsis
Teach parents all about the various drugs and side effects.
Teach parents when to seek emergency medical help
Teach parents how to optimize their child's G & D during a time of:
long term illness;
long term stress and fear;
Medications with many side effects including sedation.
and treatments that impede normal physical, cognitive and emotional G & D.
what is the most common intra abdominal cancer of childhood
the most common intraabdominal cancer of child hood is Wilms tumor
which cells do Wilms tumor arise from
Wilms tumor arise from malignant, undifferentiated cluster of primordial cells
which kidney do Wilms tumor effect the most
Wilms tumor effect the left kidney the most and it is to the adventage because left kidneys re easier to remove than the right due to its location. (little higher than the right one). 10% have it in both kidneys
how is Wilm's tumor diagnosed
Hx: weight loss, family history, history of complaint.
accurate abd exam- most children are taken to the MD because of abd protuberance, ultrasound, Ct, blood work, kidney function test, if a large mass is detected on the test, then venacavaangiogram should be done to check for any vena cava wall mass involvement.
describe Wilm's staging?
Stage 1- Tumor is limited to the kidney and resected.
Stage 2 - Tumor extends beyond kidney but is completely resected.
Stage 3 - Residual nonhematogenous tumor is confined to abdomen.
Stage 4- Hematogenous metastses; deposits are in lungs, liver bone and brain
Stage 5- bilateral renal involvement at diagnosis
what are the therapies for Wilms tumor
surgery, chemo (for all stages), radiation (for all metastasis)
how long after the Dx of wilms the surgery is done?
the surgery is done 24-48 hr after diagnosis of wilms. the whole kidney and adrenal glands are removed including any other tumor in the abdomen.
what is encapsulating a tumor?
: try very hard to maintain encapsulation while removing. Clips are placed around tumor site for radiation therapy for metastases.
what is Wilm's prognosis?
survival rates are higher. 90% survive if diagnosed early in stage 1 or 2
what is the common age for diagnose of neuroblastoma
half of the cases are less than 2. 25% in 2-4 years old
what is neuroblastoma made of
It is made of embryonic neural crest tumors that usually gives rise to the adrenal medulla and sympathetic ganglia.
what is the most common location for neuroblastoma?
they usually give rise in the adrenal gland or retroperitoneal sympathetic chain, but other sites include head neck, chest and pelvis.
how is neuroblastoma diagnosed?
it is the silent tumor. 70% metastasis has already occurred at time of diagnose. other diagnostic criteria are KUB, CT, X-ray, IV pylegram.
what to look for in urine excretion of pt with neuroblastoma?
Urinary excretion of catecholomines is detected in 95% with adrenal or sympathetic tumors. Look for breakdown products in urine (VNA-(vanillylmandelic acid), HVA-(homovanillic acid), dopamine, norepinephrine).
VNA, HVA are conclusive of catecholamines in the urine. Dopamine (made in the adrenals), after it breaks down, is excreted through the urine as HVA
what are the signs and symptoms of neuroblastoma
Signs and symptoms depend on the site usually causing compression on adjacent structures.
what is related to poor prognosis and rapid growth of neuroblastoma
chromosomal abnormalities are correlated with rapid tumor growth and poor prognosis.
what includes neuroblastoma theraphy
Surgery is used to debulk the tumor and biopsy.
In early stages whole tumor is removable.
Post operative radiation is used to shrink the tumor after partial resection as been attempted.
Radiation is also used for pallitive treatment.
Chemotherapy is used for all stages
what is neuroblastoma prognosis?
If all stages are grouped together, 75% of children under 1 survive and 50% for those older than 1 year old.
does the age of the child matter in prognosis of neuroblastoma?
yes, it does. the younger the child the better the prognosis is.
does neuroblastoma show any regression?
yes, in fact it is one of the few tumors that show spontaneous regression (specially at stage 4). may be because of embryonic cell maturity of immune system fighting back.
what is the indicator of health care effectiveness for the whole population and where does U.S stands?
infant mortality and U.S. stands 27th place
why is childhood trauma different than adult?
because of the developmental stage of the child, the type of injury, and the response to the injury and treatment.
what childhood characteristics increases the risk for trauma?
-light body weight
-large liver and spleen
-natural curiosity without knowing the danger.
what are the adolescence characteristics that increases the risk for trauma?
-"gawky" stage: bone growth outstrips muscle growth and they have a hard time controlling movement.
-Peer pressure to do things for which their bodies are not ready. Specially boys get the dares and then get hurt.
-Concept of vulnerability is not yet present. It will not happen to me.
Do children get intentional injury?
yes, in fact 25% of all FRACTURES in children under 3 years old are a result of abuse.
if a nurse suspect an abuse, what should she note?
a)the guardians report of details of the mechanism of injury, and the injury the injury itself, and see if they are congruent. If we see kids in the ER with this kind of injury, and parents provide story that does not match up, you should question further. Write down the facts and your concerns. document very clearly
b) The child's behaviors and whether they are expected. Children are loyal to the parent. Some times even abusing them, they still tend to go to the parents. If they have been abused a lot, they are silent and don't want to protect parents. They just say I am ok even though bleeding. Take history of the child and the parent in a different room.
c) x-rays that reflect various fractures all in different stages of healing. Ppl who abuse their children are sick. We as nurses need to protect the child first and then get parents the help
The goal: Helping this family. If child abuse is occurring, the family system is ill and needs our help.
do fire arms cause trauma in children?
yes, they do. in fact 7% of the trauma death is caused by fire work.
does homicides cause trauma?
yes, 10% of all childhood deaths are related to homicide. mainly adolescents.
how can we prevent childhood trauma?
MVA: car seats, airbags, supervision, driver's education, intoxication
Burns: hot water tanks less than 110F- 120F, smoke detectors, fireworks safety, matches
Drowning: supervision 100% of the time, swim lessons, pool covers, intoxication in boats, toilet covers.
Falls: supervision, gates, window guards
Bicycles: helmets, teach safety, reflectors
Firearms: Storage, need
Sports Injuries: proper equipment, warm ups, de-emphasize competition
Poisoning: safe storage for all potential poisons, meds, cleaners, hobbies; ventilation- lemon oil is the most toxic
describe the physical changes of adolescents?
-rapidly accelerated growth
-physical changes of secondary sex characteristics
what are the cognitive changes in adolescents?
-ability for abstract thought
- finding new values
- comparison to peers to find "normality".
how do adolescents try to establish identity?
they try to establish identity by
- finding new roles
- measuring self in attractiveness by acceptance and
rejection of peers.
- conformity to group norms
-preoccupation with rapid body changes
how would you describe adolescents relationship with parents?
-defining dependence -independence boundaries
- ambivalence b/t attachment and detachment
how would you describe adolescents relationship with peers?
-seeks peer affiliations
- upsurge of close and strong same-sex friendships
-struggle for mastery within peers group
-exploration to attract opposite sex
what are some sexual development in adolescents?
-self exploration, internal identification of sexual
identity and evaluation
- development of 'dating'.
-development of ability to be intimate
- later...public ID as gay, lesbian or bisexual
what are some psychological changes in adolescents?
-mood swings; daydreaming; anger outburst;
- increase introspection; difficulty asking for help
-feelings of inadequacy; withdrawal
describe hormonal changes related to puberty
Hypothalamus releases GnRH (gonadotropin-releasing hormone) stimulating the anterior pituitary gland.
Pituitary releases FSH (follicle stimulating hormone) and LH (luteinizing hormone), stimulating the gonads
Gonads release estrogen (girl) or testosterone (boy) and CREATE secondary sex characteristics and sperm (boys) and MATURATION of ovum (girls).
what to remember about sperm and ovum development?
remember, sperms are created new and ovum matures because girls are born with ovum
at what age do girls get breast enlargement and pubic hair growth?
breast development and pubic hair varies greatly
with race: range is 7 to 18- African Americans
(7 -13) are earlier than Caucasian girls (12-18)
what is precocious puberty for girls?
precocious puberty is breast development or pubic
hair before 7 (Caucasian) or 6 (African American)
when is puberty considered delay in girls?
pubertal delay is when breast development has not started by 13 or menarche has not started 2.5 yrs after beginning of breast development
when do boys get height growth?
boys height growth: range 10.5 and 17.5 and sometimes more later. Peak at 14.
at what age does penis growth occur and what is the important point to remember?
range 10.5 to 16.5 years. remember scrotal changes before penis growth.
why growing up is so risky?
-need for independence and testing it.
-able to drive
-inclination to take risks
-feeling of indestructibility
-need to discharge energy (often without thought)
-need for peer approval; attempt hazardous feats
-peak time for participation in sports
-access to tools
-developing ability to be responsible for own actions.
what are some nursing education to reduce the risk of injuries in adolescents?
-discourage tanning booth and encourage sunscreen
-discourage all tobacco use.
-educate on issues of drug abuse and considerations with drug use.
-instruct about the use and abuse of firearms.
-promote use of safety gear for sports.
-teach about the signs of depression in self and others and to tell a helpful person.
-instruct about dietary habits, nutrition, exercise and avoidance of obesity.
Promotion of healthy body image and weight.
describe the rate of depression in adolescents? is it more in boys or girls
Depression between 9th and 12th Grade: 36% of girls and 22% of boys.
what is the third leading cause of death in adolescents?
suicide. girls attempt more suicide than boys but boys are more successful than girls.
what is suicide rate increasing?
1: Has increased dramatically in the past few decades perhaps because of the discrepancy between what they have been led to anticipate and what they are truly able to obtain.
2: Desensitization to death by viewing it in the media.
3: Suicide may be romanticized and have copycat issues.
4: Isolation from death and it's pain because family is geographically far away.
5: Suicide rates have paralleled increasing violence and child poverty rates, increasing divorce decreasing rates of parental involvement.
6: Roles are changing, earlier onset of puberty, need for higher educational attainment.
7: Parents jobs include much travel.
what is the major difference between suicide attempt and success
the availability of lethal weapon which is also the most common way to commit suicide for both genders.
what are the suicide risk factor?
Previous suicide attempt
Suicide by family member or friend
Hx of neglect, physical and/or sexual abuse
Past psychiatric hospitalization
Death of a parent at a young age
Depression, hopelessness, drug/alcohol abuse, impulsiveness, low frustration tolerance, excessive guilt/humiliation, need to do things perfectly.
Body image problems, ADHD, Chronic illness, learning disorders
When the adolescent has gender identity or sexual identity concerns, especially in an unsupportive environment.
what are the warning signs of suicide?
Preoccupation with death
Giving away cherished items
Desire to die
Loss of energy, appetite, interest, lack of sleep
Antisocial behavior: fighting, vandalism, and/or promiscuity
Withdrawn, sad, remote
Poor grades and withdrawal from activities/friends
what can nurses do to prevent suicide?
Teaching parents about risk and precipitating factors
Evaluating all teens in their care for risk and precipitating factors
Working in the community (schools, churches, community leaders, peer groups etc) about suicide prevention.
Initiating and pursuing the care of a child at risk for suicide
Teaching all children that when a peer speaks of suicide, they must tell a trusted adult about their peer.
what is anorexia?
a disease of social, behavioral, psychological and cultural components where the child has a distorted fear of body image, fear of getting fat and progressive weight loss because of self starvation (.5% of adolescent girls)
what is bulemia?
a disease of social, behavioral, psychological and cultural components where the child has a distorted fear of body image, fear of getting fat and is characterized by eating and purging through self induced vomiting, use of diuretics and laxatives (1-5% of adolescent girls).
(incidence in males is 1/10 that of females)
what are the anorexia diagnostic creteria?
Weighing less than 85% of expected minimal weight for height.
Intense fear of gaining weight
Undue evaluation on the way one's body shape influences self evaluation.
Denial of the seriousness of present low body weight.
Is postmenarcheal females: amenorrhea for 3 consecutive months
what are the diagnostic creteria for bulemia?
Eating a large amount of food in a short time and a feeling that she/he is unable to stop and may cause (not always)....,
Recurrent self-induced vomiting, laxative use, diuretic use, fasting and/or exercise to compensate for eating large amounts.
This occurs twice per week over a 3 month period
Undue evaluation on the way one's body shape influences self evaluation.
what are the ethiology of these eating disorders?
Evidence of brain imaging shows physiologic issues with the serotonin affects on appetite control however, most evidence points to family psychological associations such as:
-difficulty managing conflict, poor communication styles, child perception of high parental expectations for achievement and appearance, devaluation of the mother and maternal role and marital tension.
Child may have other psych diagnoses such as affective disorders, anxiety disorder, OCD and personality disorders.
what are characteristics of anorexia?
Turns away from food to cope
Negates the feminine role
OCD and "model" child
High achiever and maintains rigid control
Body image distortion and denies illness
85% of minimal weight
Usually not sexually active
what are characteristics of bulemia?
Turns to food to cope
Aspires to the feminine role
Impulsive with variable school performance
Less frequent body image distortion and recognizes illness
Normal or overweight
Often sexually active
what are some clinical consequenc of anorexia?
Hypotension, bradycardia, hypothermia (low wgt). Prolonged QT interval on EKG
Dry skin, lanugo, breast atrophy.
Severe constipation from lack of motility.
Amenorrhea + Osteoporosis (? Estrogen and Vit D deficient?)
Mitral Valve prolapse because of intravascular volume depletion
what are some clinical characteristics of both anorexia and bulemia?
Russell's sign: back of hand lesions from teeth from frequent induction of vomiting.
Swelling of parotid glands and submandibular glands from frequent vomiting
Erosion of enamel from back of the teeth due to frequent vomiting
what are some of the treatments available for eating disorder and how can these be managed?
Nutrition: immediate life care...IV, NG tubes and dietary adherence for healthy weight restoration
Goal for weight gain is 1 kg per week.
Close supervision during and 1 ½ hours after meals is necessary since the patient denies the problem.
Contract for a feeding tube removal or insertion may be necessary.
Team work with nutritionist: MD's, CNSs, therapist specialized in eating disorders
Therapy for AN and BN:
Family therapy looking at roles, conflicts, communication, performance, expectations and parental attitudes toward dieting and exercise.
Pharmacotherapy includes SSRI's tricyclics anti-anxiety meds.
Co morbid psych issues should be treated with those specific medications.
Appetite stimulants have not been found to help.
what is anorexia prognosis?
AN Prognosis: 50% do well.
25% have relapses and do moderately well and another 25% do poorly with frequent hospitalization and relapses.
Ultimately, AN has a 6.6 % mortality rate (54% because of complications of the eating disorder, 27% due to suicide and 19% from unknown causes).
how would you define gay and lesbian identities?
People who feel their primary emotional, spiritual , physical and sexual connection with people of the same gender.
how would you define bisexual identities?
People who feel their primary emotional, spiritual , physical and sexual connection with people of either gender (this does not denote that they are at the same time).
what are the three sexual concepts?
Biological sex (ie. XX, XY, XXY, XYY, XO, XXX)
Sexual identity (hetero/homosexual continuum and gay, lesbian, bisexual identity)
Gender identity (femininity/masculinity continuum or transsexual
does gay and lesbian identities are chacterized by sex behaviour?
no they are not. it is not true that a person who has had or wants sex with the same sex is gay or lesbian. Gay and lesbian identities are not defined by sex behavior
what are some stressors for gay/lesbian identities?
For those in the closet (undisclosed publically):
2) fear of disclosure and loss of loved ones (rejection). Covering up all that may implicate same sex love/attraction.
3) Lack of integrity between how one feels and how one lives. Lying to loved ones....
For those out of the closet (disclosed publically)
2) verbal and physical violence
3) family pressure, rejection and loss of home.
4) Forced "reparative" therapy
5) Rejection from spiritual community (religion)
what are some nursing care topics and sensitivities related to gay/lesbian?
Assess the adolescent for supports and burdens including family support, violence from family and peers, and stability of his home.
Do not assume sexual identity and values by stereotypes (only 10 % fall under stereotypes).
Assess the adolescent for depression, suicidal ideation, and drug and alcohol use.
Do not assume that the adolescent is sexually active even if he/she declare their sexual identity.
Do not assume that they do not have heterosexual sex.
Discuss the degree of disclosure with which they live. Eg. Do their parents know and are they supportive? Violent? In denial? Are they 'out' at school? Do they have supportive friends?
Do not blindly recommend that they come out to their family. This may cause violence and/or homelessness and all the issues of street living...
Recommend organization for support. Know them in the place of residence (many in SF, few in OK!). There are many online.
If parents are having trouble with acceptance (on the average it takes 7 yrs), refer them to the local chapter of PFLAG (parents and friends of lesbians and gays).