Wilms tumor, pediatric

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Overview

Rare cancer involving the kidneys
Possibly affecting one or both kidneys
Also called nephroblastoma

Overview-Pathophysiology

Abnormal renal development leads to altered cellular function responsible for differentiation of the tubules and glomerulus.
Several tumor suppressor genes appear to be involved but the exact mechanism of how they play a role in the development of Wilms tumor is unknown.

Overview-Causes

Unknown

Overview-Incidence

Wilms' tumor accounts for approximately 7% of all childhood cancers.
It is the most common renal malignancy in children and the fourth most common childhood cancer.
Approximately 500 new cases are diagnosed each year.
About two-thirds of the cases in the United States are diagnosed before age 5, with most cases diagnosed before age 10.
Blacks are more likely than whites to develop Wilms tumor.
In some children, Wilms tumor occurs with other congenital syndromes.

Overview-Complications

Metastasis
Impaired renal function
Heart failure (due to chemotherapy)
Pulmonary dysfunction (due to radiation)
Secondary malignancies
Hemorrhage
Wound infection

Assessment-History

Abdominal pain
Fever
Anorexia
Constipation
Nausea

Assessment-Physical Findings

Palpable or visible abdominal mass
Abdominal asymmetry
Hypertension
Adventitious breath sounds (if metastasis)
Lymphadenopathy
Hypertension

Diagnostic Test Results-Laboratory

Urinalysis may show hematuria or leukocytes.
Liver function tests may be abnormal with metastasis.

Diagnostic Test Results-Imaging

Renal or abdominal ultrasound identifies the tumor.
Computed tomography or magnetic resonance imaging of the abdomen and chest identify the tumor and possible metastasis.

Treatment-General

Supportive care
Radiation therapy (typically for stages III and IV disease)

Treatment-Diet

Well-balanced diet

Treatment-Activity

As tolerated

Treatment-Medications

Chemotherapeutic protocols with such agents as vincristine sulfate, dactinomycin, doxorubicin hydrochloride, cyclophosphamide, and etoposide phosphate

Treatment-Surgery

Nephrectomy (simple, partial, or radical)
Central venous access device insertion

Nursing Considerations-Nursing Diagnoses

Anxiety
Compromised family coping
Grieving
Imbalanced nutrition: Less than body requirements
Risk for ineffective renal perfusion
Risk for infection

Nursing Considerations-Expected Outcomes

verbalize feelings of reduced anxiety
demonstrate positive coping strategies
express feelings about the cancer diagnosis
maintain adequate nutritional intake with weight within acceptable range
remain free from signs and symptoms of infection
maintain urine output within acceptable parameters.

Nursing Considerations-Nursing Interventions

Avoid abdominal palpation.
Encourage verbalization of feelings and fears; allow time for the child and family to cope with the disorder and the prognosis.
Provide comfort measures, as appropriate.
Provide adequate hydration and nutrition; offer a well-balanced diet with appropriate food choices and snacks.
Obtain a daily weight.
Anticipate the need for insertion of a central venous access device for chemotherapy administration. Prepare the child and family for insertion and provide central venous access site care, ensuring patency.
Institute safety and infection control precautions, as indicated.
Cluster nursing activities to ensure adequate rest periods, and allow time for uninterrupted rest. Gradually increase the child's activity, as tolerated.
Provide care measures to address nausea, vomiting, hair loss, and other adverse reactions to chemotherapeutic agents.
Obtain laboratory specimens to evaluate renal function preoperatively and postoperatively.
Prepare the child and family physically and psychologically for surgery, as appropriate. Explain preoperative and postoperative procedures and equipment.
Provide post-operative care, including surgical site care, vital signs, renal and gastrointestinal functioning, and pain management.

Nursing Considerations-Monitoring

Vital signs
Renal function
Coping strategies
Adverse effects of treatment
Hydration and nutritional status
Daily weight
Surgical site (postoperatively)
Signs and symptoms of bleeding and infection (postoperatively)

Nursing Considerations-Associated Nursing Procedures

Axillary temperature assessment, pediatric
Blood pressure assessment, pediatric
Cardiopulmonary status monitoring, pediatric
Care plan preparation
Central venous access catheter flushing, pediatric
Central venous access catheter injection cap change, pediatric
Central venous access catheter insertion, assisting, pediatric
Central venous access catheter removal, pediatric
Central venous access device, declotting
Central venous access device dressing change
Chemotherapeutic drug administration, pediatric
Discharge, pediatric
Feeding
Hand hygiene
IV bag preparation
IV catheter removal, pediatric
IV dressing change, pediatric
IV pump use
IV secondary line drug infusion
IV solution change
IV tubing change, pediatric
IV volume-control set preparation
Oral care, child age 3 and older
Oral care, toddler
Oral drug administration, older child
Oral drug administration, toddler
Oral temperature assessment, pediatric
Preoperative care, pediatric
Priming IV tubing
Pulse assessment, pediatric
Pulse oximetry, pediatric
Rectal temperature assessment, pediatric
Respiratory assessment, pediatric
Standard precautions
Transfer to another room, pediatric
Venipuncture, pediatric
Weight measurement, child
Wound care, pediatric

Patient Teaching-General

the disorder, diagnosis, and treatment, including protocols for chemotherapy administration and possible radiation therapy (depending on the stage of the disease)
prescribed medications, including drug names, dosages, rationales for use, schedule of administration, and frequency and duration of therapy
possible adverse effects of chemotherapeutic regimen
the danger signs and symptoms to report to a practitioner
measures to minimize or prevent possible adverse effects of chemotherapy, such as the need to use a soft toothbrush and to avoid hot, spicy foods and commercial mouthwashes
signs and symptoms of infection
care of the surgical site, as indicated
the importance of protecting the remaining kidney from injury, such as avoiding such sports as boxing and hockey
signs and symptoms of abnormal bleeding
the importance of planned rest periods during the day
positive coping strategies
infection control precautions and measures to reduce the risk of infection
the recommended dietary plan
the importance of adhering to recommended follow-up, including visits, screening for treatment-related complications, and diagnostic testing, such as chest X-rays and abdominal ultrasounds every 6 to 8 weeks during therapy, then every 3 months for 2 years, and then every 6 months for an additional 2 years.

Patient Teaching-Discharge Planning

Refer the child and family to available resources and support services in the community.
Refer the child and family to home health care as appropriate.

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