Editor's Note

Greetings from RGUHS Journal of Nursing Sciences. I take immense pleasure in presenting Vol. 8, issue 2, of RJNS December, 2018. The RGUHS editorial Board extends its gratitude to all the authors who have contributed articles for this issue. We encourage the nursing fraternity to contribute scientific papers to this journal and thus empower knowledge and nursing profession. The editorial of this issue focuses on care of child on chemotherapy.

CARE OF CHILD ON CHEMOTHERAPY

Cancer is a leading cause of death for children and adolescents globally each year. The most common categories of childhood cancer include leukaemia, brain cancer, lymphoma and solid tumour like neuroblastoma and Wilms tumour1 Other types of childhood cancer also include rhabdomyosarcoma, osteogenic sarcoma, germ cell tumour, Ewing’s sarcoma etc.

Chemotherapy is one of the three traditional ways of treating cancer. It works systemically, affecting all rapidly dividing cells are affected, including those in the bone marrow, mucous membranes, and hair follicles.Chemotherapy is still the most common and widely used treatment for cancers in both adults and children

The side effects of chemotherapy vary according to the characteristics of the chemotherapy agents used. Among the common side effects are nausea, vomiting, bone marrow suppression causinganaemia, leukopenia and thrombocytopenia, alopecia, mucositis, anorexia, skin problems, insomnia, neurological problems, pain, exhaustion and fatigue

Nursing Management

Nausea and vomiting 

Nausea and vomiting is one of the most common and unpleasant side effects of chemotherapy. Close monitoring of dehydration and fluid electrolyte imbalances associated with nausea and vomiting is an important nursing role. Fluid replacement should be done as prescribed by clinician. Parents should be informed to avoid spicy and fatty foods and food withstrong odours,which may trigger nausea and vomiting. Offer small feedings. Encourage favourite foods. Refer to dietitian for special meals, monitor weight daily. Teach the child distraction and relaxation techniques. Give antiemetics according to orders. 

Diarrhea or constipation

Diarrhea and constipation are serious side effects in children with cancer. Diarrhea is defined as more than two or three watery defecations in 24 hours. If there are six or more watery stools in 24 hours), the child should be brought to the hospital. The cause may be infection, chemotherapy, or antibiotics. Diarrhea can lead to dehydration and electrolyte imbalance. Parents and care givers must be trained on the evaluation of the number and content of defecations and provision of balanced fluid intake. Absence of defecation for more than 48-72 hours, is called constipation. Neurotoxic effects of chemotherapy may result from inactivity and changes in eating habits. Record all output by size and description. Administer stool softeners. Report changes in stool to physician. Encourage adequate fluid intake. Teach the child and family about the importance of consuming more fluid and fibrous foods in the diet, being more active, and monitoring the frequency of defecation.

Mucositis

The most common complication causing anxiety in children with cancer is mucositis and stomatitis. Mucositis is the progressive, inflammatory, ulcerative condition of the mouth and gastric mucosal tissue. Stomatitis is characterized by pain and inflammation of the surface of the mucous membrane in the oral cavity. It develops as a direct result of chemotherapy destroying healthy cells in the mouth. Factors predicting mucositis are poor oral hygiene, radiotherapy, chemotherapy, thrombocytopenia, neutropenia and malnutrition, which prevent children from eating and drinking. There are a variety of assessment tools which can be used by nurses to diagnose mucositis in children. Oral assessments should be done by the nurse during each hospital visit. Nursing interventions include- oral hygiene (mouth care, chlorhexidine mouth wash 3-4 times) ,giving sips of oral fluids, avoiding too hot or cold food, liberal amount of fluid intake, application of antifungal or antiseptic cream as prescribed and encouraging the child to take liquid or semi solid diet. 

Thrombocytopenia

Thrombocytopenia can develop due to the side effects of chemotherapy. Due to thrombocytopenia, petechia and ecchymosis can occur, and there is a risk of severe bleeding that can lead to death. Nurses should observe the child’s skin in terms of bleeding, cyanosis, petechiae and purpura. Platelet level must be monitored. Transfusion of platelet as ordered. Prevention of bleeding for which interventions include brushing with soft tooth brush, gentle, firm pressure on puncture sites, limit any activity that could cause any injury.

Neutropenia and Risk for Infection related to immunosuppression

Febrile neutropenia, is a life-threatening complication of chemotherapy. It is caused by the toxic effect of the chemotherapy on neutrophils, leading to adifficulty in managing an immune response if any infection occurs in child. It is extremely important that child and family members and health care team members take precautions for preventing infection. Hand washing is one of the most important measure in prevention of infection which must be adhered by all. Wash hands often. Maintain in isolation if needed. Monitor vital signs. Report elevation to physician. A complete blood count, electrolytes, and other laboratory tests should be performed to identify source of infection. Administer intravenous antibiotics as ordered.Use sterile technique for procedures. Do not give any live vaccines, restrictvisitors,Keep any infectious person away from child, personal hygiene of child and care giver must be maintained. Teach the care givers the signs and symptoms of infection to look for at home. such as fever, feeling tired, body aches, chills, cough or breathlessness, redness, abdominal pain, mouth sores, diarrhoea/rectal discomfort with bowel movement and dizziness. Fresh or dried flowers, or potted plants in patientcare areas are not allowed. Avoid taking child to crowded places.

Alopecia 

Alopecia, is not life-threatening but is the most visible side effect of chemotherapy, which can have an impact on body image and selfconfidence. Chemotherapy affects the growth of both cancerous and noncancerous cells. The root of a hair has a high blood flow, allowing for uptake of chemotherapy. Hair can be lost from all over the body (eye brows, eyelids, extremities in case of older children with body. Child and family must be counselled to opt for options such as wearing a scarf, bandana, hat, cap, or wig. Counselling must be given to overcome psychological impact of alopecia 

Fatigue

One of the most frequent and distressing side effects of cancer and chemotherapy is fatigue. Nursing management includes planning activities and ensuring plenty of rest, ensuring adequate calorie intake and correcting anaemia, plan nursing care when child is awake, provide calm and quiet environment, assist in daily activities and encourage accomplishments.

CONCLUSION

Oncology nurses must manage both the symptoms of a patient’s disease and the side effects of various cancer treatments.They must be able to evaluate each child and initiate appropriate care. Oncology nurses must have a deep understanding of common side effects of cancer treatments, especially chemotherapy as they play a key role in the care of child receiving chemotherapy including the identification and management of side effects, education, and supporting of children and the family.