Nursing Diagnosis for Wilm's Tumor

When caring for a child with a pediatric cancer, such a Wilm’s Tumor, there are many possible nursing diagnoses to analyze. Five of the major potential and/or actual problems that will need to be analyzed and dealt with are:

•  Risk for infection related to immunosuppression secondary to chemotherapeutic drugs. Children who are being treated for Wilm’s Tumor with chemotherapeutic drugs are at a significantly higher risk for infection. This is because a side effect of chemotherapy is suppression of the immune system. A functioning immune system is needed to order to effectively and efficiently fight infection. 

Actual/Potential	Related to	Plan/ Outcome	Interventions
Risk for infection (Potential)	Related to immunosuppression secondary to chemotherapeutic drugs	Plan: Maintain proper infection control techniques and educate the patient and family to do the same. Outcome: The child will not contract any infections while undergoing cancer treatment.	Observe for signs of infection (vital signs, blood draws, ect.) Educate parents/patients on infection control (meaning of daily labs (esp. fluctuations in blood cell counts), why to avoid large crowds, when to wear a mask if ill, and proper hand hygiene) Always preform proper hand hygiene in hospital setting Clean and maintain the child’s central line regularly Nursing personnel should never care for an immunosuppressed child if ill themselves

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• Risk for acute pain related to surgical site and/or disease process. Children with Wilm’s Tumor are at risk for acute pain for a couple of different reasons. Pain can originate pot-operatively after the surgical removal of the kidney. Additionally, pain can be a side effect of the disease process, either as a result of the invading tumor pressing on other organs and tissues, or after the removal as a side effect of other treatment (break down of mucus membranes, etc).  

• Altered growth and development related to inadequate nutrition secondary to side effects of therapy. Children who are treated for Wilm’s Tumor often experience alterations in their physical growth and development. Cancer treatment has the potential to negatively affect the appetite and nutritional status of a child.  

• Risk for fatigue related to drug therapy and disease state.  Children being treated for Wilm’s Tumor have the potential to experience fatigue (tiredness) as a result of side effects of the therapy, as well as the disease itself. 

• Risk for anxiety related to diagnosis and treatment outcomes.  The diagnosis and treatment of cancer can be a stressful and uncertain time for both the patient and family. New and unfamiliar diagnoses and treatments can pose a potential for the development of anxiety.

Helpful websites in understanding the nursing diagnoses related to Wilm’s Tumor are:

• http://wps.prenhall.com/wps/media/objects/354/362846/Child%20-%20Home%20Cancer.pdf
• http://nurseslabs.com/13-cancer-nursing-care-plans/

Sources:

13 Cancer Nursing Care Plans - Nurseslabs. (2013, July 14). Retrieved February 28, 2015, from http://nurseslabs.com/13-cancer-nursing-care-plans/

Nursing Care Pan: Home Care of the Child With Cancer. (n.d.). Retrieved February 28, 2015, from http://wps.prenhall.com/wps/media/objects/354/362846/Child - Home Cancer.pdf

Nursing Actions

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Cancer care is complex. The below table summarizes a small subset of the necessary nursing actions that would be required of an RN treating a child with cancer. A very helpful NCLEX review, and much more in-depth and detailed list of nursing interventions for pediatric cancer care can be found at: http://www.atitesting.com/ati_next_gen/focusedreview/data/datacontext/rm_ncc_pn_8_chp_38.pdf

Nursing Care	Reasoning
Monitor vital signs	It is important to monitor vital signs in children who are undergoing cancer treatment to assess for infection. Due to the side effects of chemotherapy, the body is at significantly higher risk for infection. Due to decreased immune system function, infections need to be treated immediately.
Daily blood draw	It is essential to monitor the blood work of children undergoing chemotherapy. A common side effect of chemotherapy is low blood counts (low platelets, hematocrit, neutrophils, etc.). Daily blood work will indicate when a blood transfusion is necessary, as well as screen for infection.
Control chemotherapy induced nausea/ vomiting	It is essential to manage the GI symptoms of chemotherapy. It is important to pre-medicate children with antiemetic medications prior to chemotherapy administration.
Assess nutritional status	Due to the GI side effects of chemotherapy, nutritional status needs to be continually assessed. It is important to encourage frequent, small meals, avoid strong odors, and provide tube feeding when deemed necessary.
Control pain	Pain management is extremely important in treatment of cancer. Pain should be assessed frequently both post-op and throughout chemotherapy treatment.
Implement bowel regimen	Constipation is a common side effect of pain management. It is important to assess output, and implement a bowel regimen if indicated. Untreated constipation can cause discomfort and obstruction.
Provide oral care	Ulceration of mucus membranes is a common side effect of chemotherapy.  Providing high quality and regular oral care will decrease the risk oral ulceration. This is especially important as ulceration creates a risk for infection which can be detrimental in immune-compromised patients.
Provide patient and family education	It is important to educate the patient and family in order to create a realistic and clear understanding of the situation. Education should include – disease process, duration of treatment, expected side effects, plan of care, and rationale for procedures and interventions.
Assess patient and family coping skills	Cancer treatment is stressful for both the patient, as well as the family. It is important to assess coping skills, and provide resources when necessary.
Involve other disciplines in care	Cancer treatment requires a multidisciplinary approach. Involve other disciplines such as spiritual care, social work, nutrition, and respiratory therapy to have the best outcome of care.

Sources:

NURSING CARE OF CHILDREN WITH SySTEM DISORDERS - Pediatric Cancers. (n.d.). Retrieved February 18, 2015, from http://www.atitesting.com/ati_next_gen/focusedreview/data/datacontext/rm_ncc_pn_8_chp_38.pdf

Wilms' Tumor (Nephroblastoma) - RNpedia.com. (2015, January 1). Retrieved February 18, 2015, from http://www.rnpedia.com/home/notes/medical-surgical-nursing-notes/wilms-tumor-nephroblastoma

Treatment of Wilm's Tumor

http://medimoon.com/2012/08/chemotherapy-could-sustain-tumour-growth-and-produce-resistance-for-further-treatment/

Following the surgical removal of the affected organ(s), the child will also be stated on a chemotherapy regimen. Chemotherapy is a cocktail of powerful drugs designed to target and kill cancer cells.  In cases where both kidneys are affected, or the tumor has spread to distant areas of the body, chemotherapy is administered prior to surgery in an attempt to shrink the tumors present throughout the body, making surgical removal easier.  

Although there are two different treatments available for Wilm’s tumor, they are almost always used in conjunction. The treatments are compared in the table below.

	Surgery	Chemotherapy
Duration of treatment	Single day	Several months *duration depends on stage and histology
Route treatment administered	Incision at site of tumor	Administered through central catheter inserted in the heart and delivered systemically
Side effects	Variable	Numerous

In rare cases, radiation treatment is also administered in conjunction with surgery and chemotherapy.

http://www.benaroberts.com/2014/04/common-side-effects-of-chemotherapy-on-the-body.html

The side effects of Wilm’s Tumor treatment will come primarily from the chemotherapy drugs. Side effects from chemotherapy include: nausea, vomiting, hair loss, loss of appetite, mouth sores, gastrointestinal disturbances, decreased energy, increased chance of infection, increased bruising, low platelets, low hemoglobin, and low ANC (absolute neutrophil count). The side effects from chemotherapy arise as a result of the fact that chemo targets cells in the body that are rapidly dividing. Although cancer cells fall into this category, so do many other cells including the cells in the GI tract, hair follicles, and bone marrow. Although the side effects of chemo can be numerous, there are many medications that will be administered with the chemotherapy to help mask the side effects.

Side Effect	Response
Nausea / vomiting	Administer anti-nausea medication
Mouth sores	Sodium bicarbonate rinses & pain management
Infection	Administer antibiotics (if present), avoid large crowds (to avoid risk of infection)
Low platelets/ blood cells	Administer blood transfusion

For more information, go to:

•        American Cancer Society - http://www.cancer.org/cancer/wilmstumor/detailedguide/wilms-tumor-treating-chemotherapy & http://www.cancer.org/cancer/wilmstumor/detailedguide/wilms-tumor-treating-by-stage
•       Mayo Clinic - http://www.mayoclinic.org/diseases-conditions/wilms-tumor/basics/treatment/con-20043492
•       St. Jude’s Children’s Research Hospital - http://www.stjude.org/wilms-tumor

Sources:

Chemotherapy for Wilms tumors. (2013, September 17). Retrieved February 14, 2015, from http://www.cancer.org/cancer/wilmstumor/detailedguide/wilms-tumor-treating-chemotherapy

Treatment by type and stage of Wilms tumor. (2013, September 17). Retrieved February 14, 2015, from http://www.cancer.org/cancer/wilmstumor/detailedguide/wilms-tumor-treating-by-stage

Wilms' tumor. (2015, January 1). Retrieved February 14, 2015, from http://www.mayoclinic.org/diseases-conditions/wilms-tumor/basics/treatment/con-20043492

Wilms Tumor. (2015, January 1). Retrieved February 14, 2015, from http://www.stjude.org/wilms-tumor