MCN 304 CELLULAR ABBERATION

What is cancer?

Normal cells grow and divide, then eventually die. Cancer occurs when the body is unable to regulate cell growth, leading to an overgrowth of abnormal cells.

Benign v. Malignant o Benign: overgrowth of cells that are NOT cancerous o Malignant: overgrowth of cells that ARE cancerous Neoplasia- comes from the word neoplasm which means new growth, it usually refers to a new abnormal growth that does not respond to normal-growth mechanisms. CAUSES OF NEOPLASTIC Growth: UNKNOWN Exposure in Utero Cancer survivor Cell Mutation Theory Viral Theory Another theory is that tumor suppressor cells exist in some individuals and not in others.

Health Promotion and Risk Management Urging parents to reduce childrens exposure to secondary cigarette smoke and urging adolescents not to begin smoking can help reduce the incidence of lung cancer when they reach adulthood. Applying sunscreen and reducing the overall time of sun exposure for children can help reduce the development of skin cancer in later life. Urge children to continue health appointments so that any additional tumor development can be discovered is another important preventive measure. A vaccine against Human Papilloma Virus (HPV), which leads to cervical cancer. Assessment: Chief Concern: Weight loss, loss of appetite, easy bruising, swelling in a body part, headache, eye deviations Past medical History: Family member with a history of cancer Physical Examination: Swollen Lymph Glands (Hodgkins Disease) Nausea and vomiting (Brain Tumor) Weight Loss ( Ecchymotic marks (Leukemia) Headache (Brain Tumor) Eye deviations (brain tumor, retinoblastoma)

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 Palpable mass in abdomen (neuroblastoma or Wilms Tumor) Pain and swelling in a large joint (osteosarcoma or Ewings sarcoma) Physical and Laboaratory Examination Any suspicion of a malignancy requires a thorough physical examination Radiography Sonography Magnetic Resonance Imaging (MRI) Blood Analysis And Biopsy- is the surgical removal of tissue cells for laboratory analysis and done on ambulatory basis. One example is bone marrow aspiration Tumor Staging- is a procedure by which a malignant tumors extent and progress are documented. Knowing the stage of the tumor helps the health care team design an effective treatment program, establish an accurate prognosis, and evaluate the progress or regression of the disease. Stage 1- refers to a tumor that can be completely removed surgically Stage II- refers to a tumor that cannot be completely removed surgically Stage III and Stage IV- designate tumors that can have extended beyond the original site or have spread systematically (metastasis). TNM System- describes the tumors size (T), its presence on the lymph nodes (N) and its metastasis (M) or spread to other organs, if any. Cancer Treatment Measures used with Children: The treatment of a child with cancer focuses on devising ways to kill the growth of the abnormal cells while protecting normal surroundings cells. Radiation Therapy-changes the DNA component of a cell nucleus to a point at which the cell cannot replicate DNA material and thereby inhibits further cell division. Not effective on cells that have very low oxygen content Radiation schedules are designed so that therapy occurs over a period of 1 to 6 weeks Radioresistant- tumors that require such massive dose of radiation. Immediate side effects: Radiation sickness- anorexia, nausea, vomiting <occurs if gastrointestinal tract is irradiated>. A child may need to receive an antiemetic before each procedure Extreme fatigue Skin reactions such a erythema and tenderness Longterm side effects Asymmetric growth of bones, easy fracturing, scoliosis, kyphosis or spinal shortening Bones are vulnerable during times of rapid growth. Scoliosis and Khyphosis can be avoided if entire vertebra is irradiated rather than only one side or the other. Radiation to the head and neck can result in long term thyroid, hypothalamic-pituitary, and gland dysfunction. This may result in growth hormone deficiency or hypothalamic-pituitary stimulation to the thyroid gland can be treated with hormone therapy in the coming years. Ovaries and Testes- results to infertility Demyelination and necrosis of the white matter of the brain which results in symptoms of lethargy, sleepiness and seizures.

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Effects on the gray matter cause learning disabilities. May result in chronic pneumonitis and pulmonary fibrosis or thickening. Pericardial thickening and reduced heart expandability. Chronic malabsorption from changes in intestinal villi.

The long term effects should be explained to the parents as a part of obtaining informed consent. Caring for the child receiving radiation therapy Skin care Expose irradiated area to air but not to direct heat or sunlight. Avoid lengthy soaks in bath water or swimming pools. Encourage clothing that fits loosely over irradiated areas. Do not apply creams or lotions unless prescribed ( to avoid drying) Nutrition Admister antiemetics as prescribed. Encourage high calorie meals. Provide foods identified by child as special favorites. Serve easy to swallow foods at tolerable temperatures. Hydration Reduce amounts of fresh fruits and vegetables rich in cellulose and eliminate apple juice from childs diet. Because this may cause diarrhea and subsequent fluid loss Activity Provide adequate rest periods . Recommend mild activity that does not stress bones that may be weak by radiation. Chemotherapy Chemotherapeutic agent- one that is capable of destroying malignant cells. Types of Chemotherapetic Agents: When administering such agents wear gloves and wash your hands well afterward to prevent skin exposure and absorption of the drug. Alkalyting Agents- interfere with DNA synthesis. They are cell-cycle specific (they are most effective against cells in the G and S phases of growth) Example: cyclophosphamide (Cytoxan) and chlorambucil ( Leukeran) Antimetabolites- resemble natural products that a cell incorporates them into structure. However, they are not the natural product, so the cell cannot function or replicate with them in its structure and will die. Example: Methotrexate (Folex PFS), a folic acid antagonist Plant Alkaloids- interfere with cell mitosis (M Phase) Examplke: vincristine (Oncovin) and vinblastine (Velban) Antibiotics- are effective in destroying malignant cells by impairing DNA synthesis. These are not cell-cycle specific. Example: dactinomycin (Cosmegen), doxorubicin ( Adriamycin) Nitrosoureas- disrupt protein synthesis thereby interfering with DNA synthesis. Because these drugs cross the blood-brain barrier, they are effective as chemotherapy agents in brain tumor therapy. Example carmustine (BCNU)

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 Enzymes- Body cells need a ready supply of L-asparagine (an essential amino acid) to grow. L-Asparagine ( Elspar), a chemotherapeutic agent is an enzyme that converts LAsparagine into L-Aspartic Acid therby making L-Asparagine unavailabale for leukemia cell growth. Steroids- a corticosteroid most frequently binds to DNA to inhibit mitosis and probably RNA synthesis in cells. When it is added to therapy, the formation of new cells is prevented. Immunotherapy- is the stimulation of the bodys immune system to attempt destruction of foreign or malignant cells. The administration of bacilli Calmette-Guerin vaccine is an example of this type of therapy. The tuberculin antigen stimulates the immune system to identify and destroy an antigen, with the hope that the system will recognize foreign tumor cells and acts against them as well Interferon is an antiviral agent that prevents growth of viruses. While children are receiving chemotherapy, parents should not give them aspirin. Low virus vaccines should not be given. Side effects and Toxic reactions: Asparaginase (Elspar) Anorexia weight loss, nausea, vomiting, hepatotoxicity, central nervous system toxicity, anaphylactic reaction. Staying with the child for the first hour of infusion is important take vital signs q 15 mins for first hour to detect anaphylactic reaction. Carmustine (BCNU, BICNU) Nausea, vomiting, bone marrow depression (after 3-4 wks), hepatotoxicity. Child may notice burning sensation along vein during administration due to alcohol diluents. Chlorambucil (Leukeran) Bone marrow depression. Monitoring of WBC is necessary Cisplatin (PLatinol) Bone marrow depression, nephrotoxicity (renal dysfunction), nausea, vomiting, loss of taste, tinnitus, high frequency hearing loss. Infusion bottle must be covered with aluminum foil to keep out light or decomposition will result. Cyclophosphamide (Cytoxan) Bone marrow depression,anorexia, nausea, vomiting, stomatitis, alopecia, cystitis (hemorrhagic), hepatotoxicity. Fluid intake is encouraged, maintain IV Line to limit bladder irritation; test urine for blood and specific gravity. Cytosine arabinoside (Ara-C) Nausea, vomiting, bone marrow depression, stomatitis, alopecia, photosensitivity. Child may also need to wear sunglasses in bright light. Dacarbazine (DTIC) Bone marrow depression. Extravasation causes severe tissue damage Etoposide (Toposar) Fatigue, alopecia, nausea and vomiting. Slow IV administration is necessary to avoid to avoid irritation.

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 Doxorubicin (DaunoXome) Alopecia, bone marrow depression. Extravasation causes severe tissue damage. Ifosfamide(Ifex) Leucopenia, alopecia, hemmorhagic cystitis. Maintaining Hydrationis important to prevent cystitis Lomustine (CCNU; CeeNu) Nausea, vomiting i9n 6 hr, bone marrow depression (after 3-4 wks). Administration on an empty stomach enhances absorption. Mercaptopurine (Purinethol) Bone marrow depression, nausea, vomiting, stomatitis, hepatotoxicity. Allopurinol delays the degradation of mercaptopurine and thus increases toxicity, question order if both are to be administered. Methotrexate (MTX) Stomatitis, bone marrow depression, nausea, vomiting, alopecia, hepatotoxicity, nephrotoxocoty at high dosage. Decreased effect occurs if administered with salicylates; often followed by leucovorin to decrease toxicity to normal cells. Prednisone Weight gain, cushingoid facies, depressed systemic response to infection. Child needs support to accept changed appearance. Vincristine Constipation,alopecia, joint and muscle pain, muscle weakness. Paresthesia of fingers and toes, foot-drop may occur, may need stool softener, tissue necrosis may occur if infiltrated Interventions 1. Monitor for severe bone marrow suppression; during the period of greatest bone marrow suppression (the nadir), blood cell counts will be extremely low. 2. Monitor for infection and bleeding. 3. Protect the child from life threatening infections. 4. Monitor for nausea, vomiting, and diarrhea. 5. Administer stool softeners as prescribed. 6. Provide rectal hygiene as needed. 7. Administer antiemetics as prescribed. 8. Monitor for signs of dehydration 9. Monitor for signs of hemorrhagic cystitis. 10. Monitor for signs of peripheral neuropathy Central Venous Access Devices PERIPHERALLY INSERTED CENTRAL CATHETERS (PICC LINES) o Inserted into the antecubital fossa and passed through the basilic or cephalic vein into the superior vena cava (SVC) o Can be inserted by a specially trained registered nurse o General anesthesia is not required for insertion o Associated with low sepsis rates o Not suitable for rapid fluid replacement because of its small lumen size TUNNELED CATHETERS (HICKMAN OR BROVIAC CATHETER) o One or two Dacron cuffs or Vitacuffs on the catheter to enhance tissue ingrowth o May have one or more lumen

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Reduced risk of bacterial migration after tissue adherence to Dacron cuff or Vitacuff occurs o Easy to use for self-administered infusions o Requires daily heparin flushes o Must keep clamped at all times when not in use o Necessary to keep exit site dry GROSHONG CATHETER o Dacron cuff or Vitacuff on catheterenhances tissue ingrowth o May have one or more lumen o Minimal maintenance required o No heparin flushes required o No clamping required because of two-way valve IMPLANTED PORTS Include Port-A-Cath, Infus-A-Port, Mediport, Norport, Groshong port o Totally implantable device; consists of self-sealing injection port o Associated with reduced risk of infection o Placed completely under the skin, so no risk of external damage o No maintenance care required o Heparinized monthly and after each infusion INTERVENTIONS: Child and Family Education: Chemotherapeutic drugs affects rapidly dividing cell to include cancer cells and normal cells: a. Hair b. Mucous membrane c. Gastrointestinal tract

BONE MARROW TRANSPLANTATION This can allow higher doses of chemotherapy and radiation to be used because, in the event of severe bone marrow depression, the child can have healthy marrow restored. Immune cells in the transplanted marrow may actually help to kill remaining cancer cells in the childs circulation. Procedure: Before transplantation, the child receives a chemotherapy agent, such a s cyclophosphamide, and total-body irradiation. Bone marrow is aspirated from the child and treated to reduce the number of abnormal cells present or stem cells are removed from the circulating blood of a designated donor or donated placenta. Bone marrow or stem cells are then processed and transfused into the child intravenously. Transfusion of blood products may be necessary to maintain functional blood components until the transplanted marrow begins to function. Nursing Diagnosis: Pain related to neoplastic process in bone Imbalanced nutrition, less than body requirements related to stomatitis from radiation therapy

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 Risk for infection related to immunosuppressive effects of chemotherapy Disturbed Body Image related to loss of hair after radiation treatment Compromised family coping, related to long-term chemotherapy program Most common childhood cancers: o Leukemia (Blood) o Brain And Nervous System o Lymphatic System (Lymphoma) o Kidneys (Wilms Tumor) o Bones (Osteosarcoma & Ewings Sarcoma) o Muscles (Rhabdomyosarcoma) LEUKEMIA Distorted and uncontrolled proliferation of WBCs (leukocytes The malignant cell involved is the lymphoblast, an immature lymphocyte With rapid proliferation of immature WBCs, RBCs and platelet falls, and invasion of body organs by rapidly producing WBCs begins ETIOLOGY/PATHOPHYSIOLOGY: A malignant increase in the number of leukocytes, usually at an immature stage, in the bone marrow Leukemia affects the bone marrow, causing anemia from decreased erythrocytes, infection from neutropenia, and bleeding from decreased platelet production (thrombocytopenia) Cause is unknown and appears to involve genetic damage of cells, leading to the transformation of cells from a normal state to a malignant state. Risk factors: genetic, viral, immunological, and environmental factors and exposure to radiation, chemicals, and medications. ASSESSMENT o Infiltration of the bone marrow by malignant cells causes fever, pallor, fatigue, anorexia, hemorrhage (usually petechiae), and bone and joint pain; pathological fractures can occur as a result of bone marrow invasion with leukemic cells. o Signs of infection occur as a result of neutropenia. o The child experiences hepatosplenomegaly and lymphadenopathy. TREATMENT Treatment involves the use of chemotherapeutic agents, with or without cranial radiation. The phases of treatment include induction, which achieves a complete remission or disappearance of leukemic cells; intensification or consolidation therapy, which further decreases the tumor burden; central nervous system prophylactic therapy, which prevents leukemic cells from invading the central nervous system; and maintenance, which serves to maintain the remission phase. Classification of Leukemia ACUTE LYMPHOCYTIC LEUKEMIA Mostly lymphoblasts present in bone marrow Age of onset younger than 15 years ACUTE MYELOGENOUS LEUKEMIA Mostly myeloblasts present in bone marrow Age of onset between 15 and 39 years NURSING DIAGNOSIS:

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a. Risk for infection b. Risk for fluid volume deficit INTERVENTIONS: Avoid exposure to crowded areas to prevent infection. Infection is a major cause of death in the immunosuppressed child. Infection can occur through self-contamination or cross-contamination. Most common sites of infection are the skin (any break in the skin is a potential site of infection), respiratory tract, and gastrointestinal tract. Medical/Surgical Management: Administer prophylactic antibiotics to prevent against infection. Leukocyte transfusion Administer chemotherapy as ordered INTERVENTIONS: Protecting the Child From Infection Maintain frequent and thorough hand washing. Maintain the child in a private room and a room with high-efficiency particulate air filtration or laminar air flow system if possible. Be sure that the child's room is cleaned daily. Use strict aseptic technique for all nursing procedures. INTERVENTIONS: Monitor the white blood cell and neutrophil counts. Notify the physician if signs of infection are present, and prepare to obtain specimens for culture of open lesions, urine, and sputum. Initiate a bowel program to prevent constipation and rectal trauma. Avoid invasive procedures such as injections, rectal temperatures, and urinary catheterization. INTERVENTIONS: Bleeding The child with a platelet count less than 20,000/mL may need a platelet transfusion. For the child with severe blood loss, packed red blood cells may be prescribed Fatigue and nutrition 1. Assist the parents and child in selecting a well-balanced diet. 2. Provide small meals that require little chewing. 3. If the child cannot take oral feedings, then parenteral nutrition or enteral feedings may be prescribed. 4. Assist the child in self-care and mobility activities. 5. Allow adequate rest periods during care. 6. Do not perform activities unless they are essential. INTERVENTIONS: Protecting the Child From Bleeding Examine the child for signs and symptoms of bleeding. Handle the child gently. Measure abdominal girth; an increase can indicate internal hemorrhage. Instruct the child to use a soft toothbrush and avoid dental floss. Refers to cancers that originate in the body's lymphatic tissues. Lymphatic tissues include the lymph nodes (also called lymph glands), thymus, spleen, tonsils, adenoids, and bone marrow, as well as the channels (called lymphatics or lymph vessels) that connect them.

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 Lymphomas are divided into two broad categories, depending on the appearance of their cancerous (malignant) cells. These are known as Hodgkin's lymphoma and non-Hodgkin lymphoma (NHL). Hodgkin's Lymphoma This type of lymphoma is defined by the presence of specific malignant cells, called Reed-Sternberg cells, in the lymph nodes or in some other lymphatic tissue. Hodgkin's lymphoma affects most commonly during early and late adulthood (between ages 15 and 40 and after age 55). Symptom: o A painless enlargement of the lymph nodes (a condition known as swollen glands) located in the neck, above the collarbone, in the underarm area, or in the groin. o Other nonspecific symptoms, including fatigue, poor appetite, itching, or hives. Unexplained fever, night sweats, and weight loss are also common. Non-Hodgkin Lymphoma (NHL) It may occur at any age during childhood, but is rare before age 3. NHL is slightly more common than Hodgkin disease in kids younger than 15 years old. In non-Hodgkin lymphoma, there is malignant growth of specific types of lymphocytes (a kind of white blood cell that collects in the lymph nodes). Malignant growth of lymphocytes is also seen in one of the forms of leukemia (acute lymphoblastic leukemia, or ALL), which sometimes makes it difficult to distinguish between lymphoma and leukemia in children. In general, people with lymphoma have no or only minimal bone marrow involvement, whereas those with leukemia have extensive bone marrow involvement. Risk Factors: People with certain severe immune deficiencies including people with inherited immune defects, adults with human immunodeficiency virus (HIV) infection, or those who have been treated with immunosuppressive drugs after organ transplants. Although no lifestyle factors have been definitely linked to childhood lymphomas, kids who have received either radiation treatments or chemotherapy for other types of cancer seem to have a higher risk of developing lymphoma later in life.

Diagnosis
The following tests are commonly used: blood tests, including complete blood count (CBC) blood chemistry, including tests of liver and kidney function bone marrow biopsy or aspiration lumbar puncture (spinal tap) to check for cancer spread to the central nervous system (brain and spinal cord) ultrasound computed tomography (CT) of the chest and abdomen, and sometimes X-rays magnetic resonance imaging (MRI) bone scan, gallium scan, and/or positron emisson tomography (PET) scan (when a radioactive material is injected into the bloodstream to look for evidence of tumors throughout the body) These tests are important for determining the spread of the lymphoma within the body to guide which type of treatment should be used. Treatment Treatment of childhood lymphoma is largely determined by staging.

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 Chemotherapy is the primary form of treatment for all types of lymphoma. Radiation Short-Term and Long-Term Side Effects Intensive lymphoma chemotherapy affects the bone marrow, causing anemia and bleeding problems, and increasing the risk for serious infections. Chemotherapy and radiation treatments have many other side effects some short-term (such as hair loss, changes in skin color, increased infection risk, and nausea and vomiting) and some long-term (such heart and kidney damage, reproductive problems, thyroid problems, or the development of another cancer later in life) that parents should discuss with their doctor. Treatments Immune therapy BRAIN TUMOR Types of Brain Tumor: Cerebellar Astrocytomas- slow growing, cystic tumors that arise from the glial or support tissue of neural cells. Peak Age of Incidence: 5-8 years Medulloblastomas- fast growing tumors found most commonly in the cerebellum. Peak age of Incidence: 5-10 years Brainstem Tumors- arise from the support tissue of the neural cells. They often cause paralysis of the fifth, sixth, seventh, ninth and tenth cranial nerves. Assessment Symptoms of increased intracranial pressure: headache- occurs on arising in the morning, vision- diplopia or strabismus due to suppression of vision in one eye is usually noted. changes, vomiting- occurs on arising and does not precede a nauseas feeling an enlarging head circumference, or papilledema- may be evident in funduscopic examination Nystagmus Ataxia Seizure Late signs: lethargy, projectile vomiting and coma Diagnostic Exams: Thorough neurologic exam Skull films Bone scan Sonogram or MRI Cerebral angiography CT Scan Myelography- may be done to identify tumors that have spread into the spinal column *Lumbar Puncture must be done cautiously that may cause braintem to herniate into the spinal cord interfering with respiratory and cardiac function. Therapeutic Management Surgery Radiotherapy Chemotherapy- may be limited because many chemotherapeutic agents do not cross the the blood-brain barrier. Lomustine (CCNU) Vincristine Special Considerations during seizure:

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Completely describe any seizure activity observed, particularly the beginning movements of the seizure, because these may help to localize the point of maximum brain pressure. o Side rails should be in place for protection if a seizure occurs while the child is in bed. Preoperative Care Give stool softener to prevent straining with bowel movements. Enema increases intracranial pressure Dexamethasone ( Decadron)- given to reduce edema Phenytoin ( Dilantin) is an anticonvulsant given if child is experiencing seizures or if surgery is apt to induce seizures. Portion of the childs head should be shaved A preoperative visit to the ICU staff should also be made Postoperative Care *patients are expected to be in a comatose or extremely lethargic state, in addition, the child may require mechanical ventilation because of the pressure at the respiratory center Position the child as the surgeon describes (on the side opposite of the incision) Do not lower the head of the bed, as this may cause increased ICP due to accumulation of increased blood in the area. Monitor vital signs every 15 minutes Observe head dressings for serosanguineous drainage Regulate the rate of IV flow as prescribed Longterm effects: Neurologic and pituitary dysfunction (especially lack of growth hormone) and cognitive challenge due to cranial radiation. Nursing Diagnosis: Fear related to the diagnosis of Brain Tumor Summary Overview of Other Tumors in Children:

Osteosarcoma

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 Pathophysiology : originates from bone-forming mesenchym creating malignant osteoid tissue most common in distal femur metastasis to lung Findings: localized pain, limp, decrease in physical activity Therapeutic management: surgical approach limb salvage with prosthetic bone replacement; or amputation plus combination chemotherapy before and/or after surgery Wilm's tumor Pathophysiology : solid tumor of the renal system possibly genetic in some cases most often affecting the left kidney tumor encapsulated for extended period is staged I-V at time of resection Findings : abdominal mass characteristically firm, non-tender confined to one side Therapeutic management surgical resection combination chemotherapy, irradiation highest survival rate of all pediatric malignancies Retinoblastoma Pathophysiology: congenital malignant tumor of the retina, with evidence of genetic inheritance in certain cases Findings: cat's eye reflex (whitish glow in pupil); strabismus; red, painful eye Therapeutic management : radiation therapy, enucleation, chemotherapy treatment depends on stage of tumor, stages I-V Ewings Sarcoma Malignant tumor occurring most often in the bone marrow of the diaphyseal area (midshaft) of long bones Rhabdomyosarcoma Is a tumor of striated muscle. It arises from embryonic mesenchyme tissue that forms muscle, connective and vascular tissue. The peak age is 2-6 years with second peak at puberty. Common sites: o Eye orbit, paranasal sinuses, uterus, uterus, prostate, bladder, retroperitoneum , arms and legs. CNS invasion occurs from direct tumor extension. o Complications: o Cranial Nerve Palsy, Nuchal Rigidity, Bradycardia or bradypnea (due to brainstem compromise) o Distant metastasis most commonly occurs in lungs, bone or bone marrow. Common Sites and Associated Symptoms Orbit o Proptosis (extruding eye); visible and palpable conjunctival or eyelid mass Neck

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o Hoarseness, dysphagia; visible and palpable mass in neck Nasopharynx o Airway Obstruction, epistaxis, dysphagia, visible mass in nasal or nasopharyngeal passages Paranasal Sinuses o Swelling, pain, nasal discharge, epistaxis Middle ear o Pain, chronic otitis media, hearing loss, facial nerve palsy , mass protruding into external ear canal Vagina o Mass protruding from uterus or cervix into vagina, abnormal vaginal bleeding Trunk, extremities o Visible and palpable soft tissue mass Tes ticles o Visible and palpable soft-tissue mass Laboratory and Diagnostic: Biopsy Specimen Metastasis ruled out by: bone scan, chest radiography, CT scanning, MRI and bone marrow aspiration Therapeutic Management: Surgical removal of the tumor Chemotherapy with a gents such as vincristine, dactinomycin, cyclophosphanamide, doxorubicin, etoposide and ifosfamide. The child receives enema every 3 0r 4 weeks for 18 to 24 months Prognosis: may depend on the size of the tumor and whether metastasis was present at the time of initial diagnosis.

Skin Cancer Three types: Basal cell carcinoma a surfaceepithelial growth that manifests as a small ulcer that does not heal Squamous cell carcinoma a tumor of the epidermis that manifests as a white scaly lesion Malignant melanoma a tumor originating in melanocytes or nevi that manifests as a mole that changes in appearance Applying sunscreen or wearing protective clothing ifna child will be out in the sun for longer than 20 minutes Using tanning beds or ultraviolet light with the same precautions as sunlight Avoiding sunburn, because there is a direct association between two or more episodes of sunburn in adolescence and the development of malignant melanoma in young adulthood.

References: Pillitteri, Adele. Maternal & Child Health Nursing: Care of the Childbearing & Childrearing Family.
Philadelphia, PA: Lippincott Williams & Wilkins, 2007. Print.

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