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Identification data Name Age Sex C.R no Bed no/ Ward Religion Nationality Date of admission Diagnosis Fathers education Fathers occupation Mothers education Mothers occupation Address Informant CHIEF COMPLAINTS:The child is a known case of neuroblastoma and abmitted for surgery. HISTORY OF PRESENT ILLNESS: - Patient was apparently well when at age of 3.5 years parents noticed swelling in the abdominal and inguinal region ,accompanied by fever and loss of appetite.Initially they took treatment from some local physician but gradually the swelling also developed in cervical and axillary region.As the symptoms were not subsiding,so the patient was reffered to PGIMER. Since 07,patient is getting treatment from PGIMER and had also undergone cysles of chemotherapy. :Master Afzal :6 yrs :male :986104 : 9/Neurosurgical ward :Hindu :Indian :3/03/10 :Neuroblastoma : illiterate :Laboourer : illiterate :Housewife :Village Chatka,dist. Saharanpur(U.P) :Mother,Father

HISTORY OF PAST ILLNESS: No h/o any other significant illness in the past. PERSONAL HISTORY:Antenatal History: There was no complaints during the ante natal period. Birth History: FTNVD at home.Cried immediately after birth.There was no incidence of cord bleeding. Developmental development. Immunization History: immunized appropriate to age. FAMILY HISTORY:- No significant family history of genetic disorder present. Family Tree: History: No delay in any milestone. Normal growth and

33 yrs

30yrs

6 yrs

patient SOCIO-ECONOMIC STATUS:A low class family with minimum sanitation facility. They have access to safe drinking water and an Indian toilet.

GENERAL PHYSICAL EXAMINATION: Body built :mesomorphic Gait Height Weight Pulse RR :Normal :76 cm :11 kg :78/min :18/min

HEAD TO FOOT ASSESSMENT:Head shape Eyes Lips Nose Ear Tongue Teeth Neck Chest Abdomen Back Extremities Genitalia :normal head size and shape, no hydrocephalus. :pupils normal size, reacting to light, pale sclera :pink in color,dry lips present :normal, no abnormal discharge, no DNS :normal hearing, no discharge, wax or pus formation. : pink in color, moist,coated :teeths stained,no halitosis :normal length, no palpable lymph nodes, normal ROM. :normal chest movements, no wheezing.chest circumference 47cm :bowel sounds normal :Normal curvature of spine. :Both limbs are normal, equal in size, muscle tone is also normal :clean & healthy, no abnormal discharge.

SYSTEMIC EXAMINATION:Respiratory system:RR:18/min Normal respiration at rest Bilateral chest clear, air entry equal.

Cardiovascular system:HR: 78 bpm, S1, S2 present CFT:<3sec. All peripheral pulses are palpable. Central Nervous system:No h/o of seizures. Normal Reflexes.

Musculoskeletal system: Muscle mass decreased. Motor functions normal in both upper and lower extremities. Endocrinal system:No endocrinal dysfunction is yet noticed. No disease related to endocrine system is present. Gastrointestinal system:Bowel sounds are normal Decreased appetite Palpable mass in abdomen Genitourinary system:clean and healthy.Child is urinating & defecating normally. Integumentary system:Normal hydration, body temperature 39 0C .Skin dirty. personal hygiene not maintained.

Nursing Diagnosis 1. Hyperthermia related to underlying pathology 2. Altered nutrition,less than condition,hospitalisation body requirement related to disease

3. Activity Intolerance related to fatigue from tumor growth and bone marrow suppression 4. Risk for infection relating to hospitalisation, underlying pathology 5. Disturbed family process relating to treatment, prolonged hospitalisation 6. Knowledge deficit regarding child care CASE IN DETAILS Neuroblastoma Neuroblastoma is the most common extracranial solid tumor in infancy. It is an embryonal malignancy of the sympathetic nervous system arising from neuroblasts (pluripotent sympathetic cells). In the developing embryo, these cells invaginate, migrate along the neuraxis, and populate the sympathetic ganglia, adrenal medulla, and other sites. The pattern of distribution of these cells correlates with the sites of primary disease presentation. Pathophysiology and etiology Etiology is unknownTumors arise from embryonic neural crest cells anywhere along the craniospinal axis. Histologic picture varies greatly from tumor to tumor and even within the same tumor. Tumor Staging

Tumors are staged primarily by extent of disease; Evans staging system:

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Stage I (tumor confined to the organ or structure of origin) to stage IV (remote disease involving the skeleton, parenchymal organs, soft tissue, distant lymph nodes, or bone marrow).

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Stage IV-S refers to cases that would otherwise be stage I or II but that have remote disease confined to one or more sites, such as the liver, skin, or bone marrow, without evidence of skeletal metastasis.

Neuroblastoma is one of the few tumors that may demonstrate spontaneous remission.

Clinical Manifestations Symptoms depend on the location of the tumor and the stage of the disease.Most tumors are located within the abdomen and present as firm, nontender, irregular masses that cross the midline.

Other common signs:

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Bowel or bladder dysfunction that results from compression by a paraspinal or pelvic tumor Neurologic symptoms because of compression by the tumor on nerve roots or because of tumor extension Supraorbital ecchymosis, periorbital edema, and exophthalmos that results from metastases to the skull bones and retrobulbar soft tissue Lymphadenopathy, especially in the cervical area Bone pain with skeletal involvement Swelling of the neck or face, wheezing, dyspnea, and cough with thoracic masses Symptoms of bone marrow failure, such as anemia, bleeding, or infection General symptoms of pallor, anorexia, weight loss, and weakness with widespread metastasis

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Diagnostic Evaluation The various diagnostic tools are:

Chest and skeletal X-rays Bone scan

Bone marrow aspiration and biopsy CBC, platelet count, ferritin 24-hour urine collectionelevated excretion of homovanillic acid (HVA) and vanillylmandelic acid (VMA) Liver and kidney function tests Histologic confirmation Additional studies:
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CT scan of primary site and chest MRI areas above diaphragm Ultrasound examination Liver and spleen scan

Genetic indictors of poor prognosis include n-Myc oncogene amplification, hyperdiploid karyotype, and chromosome deletion.

Management

Surgery plays a role is diagnostic and therapeutic management.It may be either primary (before chemotherapy or radiation) or delayed/secondary (after therapy).When complete surgical resection of a stage I tumor is possible, this may be the only treatment required. Survival rate for early stages as high as 90%, advanced stage 40%.

Children with other than stage I disease generally receive a combination of surgery, radiation therapy, and chemotherapy. Drugs of choice include vincristine (Oncovin), dacarbazine (DTIC), cyclophosphamide (Cytoxan), doxorubicin (Adriamycin), cisplatin (Platinol), carboplatin (Paraplatin), ifosfamide (IFEX), and Etopside (VP-16). Influencing factors for prognosis:
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Stage of disease the earlier the stage, the better the prognosis Age infants younger than age 1 demonstrate the best survival

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Site of primary tumor children with tumors above the diaphragm appear to do better than children with abdominal tumors Pattern of metastasischildren with metastasis to the bone marrow, liver, and skin have better prognosis than those with radiographic bone involvement. Genetic factors

The use of newer chemotherapy drugs and other techniques, such as immunotherapy and bone marrow transplantation, may improve survival rates for these children.

Complications

Metastasis to the liver, soft tissue, bones, lymph nodes, bone marrow, and skin Neurologic deficits due to nerve compression

Nursing Management Nursing Assessment

Obtain a history.
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symptoms - Focus on decrease in appetite, weakness, pain, abdominal distention, or change in bowel and bladder function. Symptoms exhibited depend on the location of the primary tumor.

Perform a physical examination, including: Assess coping mechanisms of family.

Nursing Diagnoses

Anxiety of parents related to learning of diagnosis Fear of child related to diagnostic procedures and surgery or biopsy Activity Intolerance related to fatigue from tumor growth and bone marrow suppression Constipation or Bowel and Bladder Incontinence related to pressure of tumor

Risk for Infection related to bone marrow suppression from chemotherapy and radiation Acute Pain related to tumor, surgery, or progression of disease Disturbed Body Image related to hair loss

Nursing Interventions Reducing Parents' Anxiety Reducing Child's Fear Increasing Activity Tolerance Regaining Normal Bowel and Bladder Function

Assess normal elimination patterns the child had before the illness began. Keep careful intake and output records. Assess for urinary overflow incontinence and loss of bowel function, depending on the child's age. Notify health care provider if these should occur.

Preventing Infection Observe the surgical incision for erythema, drainage, or separation of the incision. Report these changes. Relieving Pain Monitor for increasing or new location of pain, indicating progression of disease (eg, fracture due to bone involvement) Promoting Acceptance of Body Chang Family Education and Health Maintenance

Teach parents about the laboratory tests and X-rays needed at diagnosis and periodically throughout therapy.

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Instruct parents about chemotherapy drugs used and their potential adverse effects. Inform parents about potential treatment methods, such as radiation therapy and bone marrow transplantation. Advise parents to use good hand-washing technique and to prevent exposure to children with communicable diseases.

Clinical picture The patient is having a abdominal tumor. The symptoms present in the patient were loss of appetite,abdominal swelling Patient had received a cycle of chemotherapy. This time is child is abmitted for surgery.The surgery planned is EL + proceed.The child has been posted for consultation with department of pediatric surgery. Bibliography 1. Kliegman and et al; Nelson textbook of Pediatrics; 18th edition; Vol.2; pages:1067-75. 2. Donna L Wong; Essentials of Pediatric Nursing; 5th edition; pages: 1045-47. 3. www.google.com(Neuroblastoma)