NURS 491 – Oncology – Leukemia Case PDF

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Oncology Nursing 491...

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NURS 491 – Oncology – Leukemia Case Majority of leukemias in childhood are acute Acute Lymphoblastic leukemia (ALL) is a malignancy of lymphocytes & accounts for 75% of all leukemias dx in children. - Average age of dx is 2-5 years old - Cause is not fully understood, said to be multifactorial. - Survival rate for children is 77%. Treatment for childhood cancer has advanced rapidly. The Cancer Competent, Safe, and ethical family nx. involves considering entire family experience of - Experience uncertainty, spiritual distress, the Families to - Loss of control, anxiety, depression, insomnia, lowered self esteem. those who have - Fear, sadness, grief, loneliness, and dependence on others. been diagnosed - Family Conflict regarding difference in opinions of treatment, code status, and what with Leukemia should/shouldn’t be done. - Financial Strain: Parents have to work, aren’t able to put in the time they’d like to for Poor Parental their sick child. Treatments are expensive. well-being  - Social Strain: Other children in family feel neglected, parent’s have less time to spend poorer child well with them. Difference in Coping Strategies between family members (anger, denial, being sensitive, insensitive) -

Nurses Role in Caring for Entire Family

Attend to entire context: Know Contextual circumstances, intrapersonal circumstances and interpersonal circumstances and understand how these influences shape the experience of the family, family health, and nursing  listen for what is significant for person/family’s life. Listen for meaning, specific concerns, and for what is not said  Recognize each family copes a different way: refer to belief system, help family find a meaning of ill person, encourage social support, help tap into social/financial support, family communication/family meetings.  Promote family routines, rituals traditions. - Avoid stereotyping or making unwarranted assumptions. Reflect on our own contextual circumstances, values and beliefs, prior to relational inquiry - Be Honest, provide all information for Informed decision making. Give family some control over illness. - Facilitate family communication when families are stressed by changes.

Risk and Prognostic Factors Associated with Childhood Leukemia

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Prognostic Factors Low WBC count @ dx. Presence and extent of CNS disease Children with CNS disease often are asymptomatic & first seen with c/o headache, cranial nerve palsies, or complants of vision changes. HIV Usuallty comes up in ages 24, otherwise increases after age 50

Risk Factors - boys > girls ( 1.2:1 ) - Caucasian - Chromosomal abnormalities: blooms syndrome, Fanconi’s anemia - Blackfan-Diamond syndrome: rare inherited bone marrow failure syndrome that leads to decrease production of RBC’s and severe anemia - Neurofibromatosis - Familial monosomy 7 - P53 mutation - Trisomy 21 (20x higher risk): most common form of Down Syndrome - Immunodeficiency syndromes - Identical twin girls ( 1.2:1 ) Caucasian Chromosomal abnormalities: blooms syndrome, Fanconi’s anemia Blackfan-Diamond syndrome: rare inherited bone marrow failure syndrome that leads to decrease production of RBC’s and severe anemia Neurofibromatosis Familial monosomy 7 P53 mutation Trisomy 21 (20x higher risk): most common form of Down Syndrome Immunodeficiency syndromes Identical twin 5%, hepatomegaly, RUQ pain, increased bilirubin, and ascites.  Tx; maintaining intravascular volume  low dose heparin infusion for prophalaxis/tx. Digestive System Problems: N/V, loss of appetite, wt. loss, diarrhea, mouth sores Tissues in mouth, stomach, and intestines are sensitive to the drugs used in the conditioning tx. Can also be caused by infection or GVHD Recurrence, gonadal dysfunction, growth failure (tx: GH), Hypothyroidism, 6) Explore in detail graft-versus-host disease… Presenting symptoms, chronic versus acute, prevention, tx GVHD is a complication that can occur after allogeneic transplantation. It is an immune mediated reaction. Source of stem cells affects incidence of GVHD. Stem cells from UCB appear to cause less GVHD.  Can be result of infection, disease, or stem cell count of donated marrow was insufficient for engraftment  Graft versus host disease (GVHD): may also have a beneficial role. Manifestations can be life threatening but sometimes benefit in preventing recurrence of disease. Signs and Symptoms of GVHD  Diarrhea, weight loss, jaundice, sore eyes & mouth, SOB & skin rashes, joint or muscle pain, Persistent cough, abdominal pain.

Chronic (>100 days after BMT) - Can occur 70 days – yrs. after transplant. - Affects 50-60% of transplant patients and is life-

Acute 45yrs, chronic GVHD Signs and Symptoms - HLA mismatch, - Donor-recipient gender mismatch. - Characterized by scleroderma-like features & persistent Treatment: Goal is to increase immune immunodeficiency suppression. - Almost every body organ can be affected - often first line is glucocorticoids in moderate - Basic effect: dermal thickening, fibrosis, and dryness, to high doses. Antithymocyte globulin (ATG) Bacterial, fungal, and viral infections are common, is often used as second line therapy. pneumonia, - Increasing the doses of cyclosporine or Treatment tacrolimus may also be beneficial but serum - Tx should be prednisone, cyclosporine, other approaches drug levels must be closely monitored include tacrolimus, MMF, phototherapy, and extracorporeal photopheresis, ATG, and thalidomide. - Patient’s who fail to respond to prednisone usually have a Can be beneficial poor prognosis 7) Family centered care is complex and a concept in nursing that aims to improve the quality of the family existence by collaboration and strengthening the family as a unit. Considering Sally’s family: -

a) What needs might they have and how will you assess these needs? - Financial, friends, family, work, school, hobbies, other siblings, Independence, family pressures, lack of routine and independence, decrease in cognitive/physical abilities, assess via throrough assessment of pt., play, parents. After assessment be honest, provide info, give reassurance, allow for choice, and allow for family. Treating pain ASAP (faces scale) distraction (bubbles, breathing, blowing, guided imagery) Teaching: explore what they know What benefits does this approach have to Sally and her family? They feel they can trust HCP’s, feel better supported, We come to their level instead of remaining distant, making all decisions etc. Get the impression we understand and feel for them, that we’re gonna help them with this battle Reassure them that they’re not alone. Decrease anxieties and uncertainties. Increase independence, give family sense of control, decrease separation anxiety from family/peers. Look Above for more Psychosocial Care. Resource allocation in healthcare can be a controversial issue. Read the article entitled “The cost of drugs: breaking the bank to stay alive” or find a news item or article that deals with resource allocation in healthcare. After reading it, consider the following for discussion: Ethics Focuses on: fairness in allocating resources to meet health needs. When resources are scarce, an ethical approach to priority setting seeks fair distribution of available resources w/in competing health needs. Article proposes Canada gets a national catastrophic drug plan because too many patients are suffering with undue financial hardship. a) The levels at which decisions are made – who decides? - Government decides who gets what funding, pharmaceuticals determine price b) The ethical issues that may arise, what is fair? What ethical frameworks and principles apply? - Decisions should be based on reasons that fair-minded people can agree are relevant under the circumstances - There should be opportunities to revisit and revise decisions in light of further evidence or arguments. c) Quality versus quantity. d) Needs: more drugs for less money. High prices of anti-emetics and other meds used for side effects of chemo that are not payed for by Medicare leads to significant financial strain. e) Equality: Right now rich are at a much higher advantage. Those who can’t afford treatments, are not getting the b) -

meds they need  further health concerns. Resources distributed more to higher socioeconomic class. - What you pay is dependent on where you live and where they work. Young, self employed, middle-income earners in smaller provinces are the most vulnerable. - There’s many conflicts re. who’s in most need, there’s always a shortage of resources and often decisions aren’t purely based off the medical dimension. (this patient’s sicker) but social dimension as well (this patient’s younger so she should get it, this patient has been waiting longer, this patient preference) - Priority setting needs to go beyond evidence-based medicine and economics to ensure fairness in allocating limited resources F) Consider all sides of the issues: - Although there have been many promises to create a national catastrophic drug plan, the sticking point is money. Prescription drug spending exceeds 25 billion annually with almost half coming from the public purse. The challenge in public policy terms, is how to help those in need without spending more on those who already have coverage. - For one lady however, she claimed she would be dead if she didn’t have private drug insurance. That, or be living in a hospital or nursing home which is also a great expense to the government....