Bone marrow suppression, or myelosuppression, is a common and potentially life-threatening complication of cancer and cancer treatment in children and adolescents. Bone marrow function may be impaired both by the disease process and chemotherapy, interfering with healthy production of white blood cells (WBCs), red blood cells (RBCs), and platelets. Complications include the increased risk of infection due to a reduction in the circulating number of neutrophils, anemia from decreased RBCs necessary for tissue and organ oxygenation, and an increased risk of bleeding due to diminished platelets that are required for blood clotting. Recognition and prompt response to the complications of myelosuppression is essential [21].

The nurse is responsible for promotion of good hand washing and serves as a role model for infection control by thorough demonstration of hand sanitation techniques for the patients, families, visitors, and other health care personnel on the unit. If water, soap, and a disposable towel are not available, the use of alcohol-based hand sanitizer is recommended [28]. It is essential that nurses demonstrate and observe good hand washing with newly diagnosed patients and families so the crucial role of hand washing in preventing the spread of infection is understood [29]. The nurse must also be vigilant about the presence of an adequate supply of hand washing/sanitizing materials in the patient care area to promote proper hand hygiene by clinicians, family members, and visitors [27]. Children and adolescents may arrive on the unit with contagious infections. Adequate measures must be taken to isolate patients who potentially contagious, particularly in crowded settings where bathrooms are shared or plumbing are suboptimal. In addition, visitors should be screened for symptoms of infections conditions, such as fever, cough, runny nose, sore throat, diarrhea, skin rashes, or open wounds. Other preventative strategies include prohibiting the use of rectal thermometers or suppositories, educating the patient and family to avoid contact with people who are ill, and encouraging good mouth care and daily hygiene.

Gastrointestinal (GI) disruption is a common complication of cancer therapy. Mucosal cells divide rapidly, so are particularly sensitive to chemotherapy and radiation. Compromise of the mucosal barriers increases the risk of infection, dehydration, pain, bleeding, and malnutrition.

Mucositis is the inflammation of the mucous membranes and is a common side effect of chemotherapy. It can be mild to severe, and may be dose-limiting, particularly in children receiving high dose, intensive chemotherapy, radiation of the head and neck, or undergoing bone marrow transplant. Stomatitis refers specifically to an inflammation of the oral mucosa. Clinical manifestations include redness, edema, and ulceration of the mucus membranes, gums, and tongue. Symptoms include pain, changes in taste, cracked lips, and sore throat.

Nursing interventions include assessment of the oral cavity at least daily, pain assessment, promotion of good oral hygiene (including use of a soft toothbrush and toothpaste), and evaluation of oral intake and hydration status [29]. Topical agents or systemic analgesics ranging from acetaminophen to continuous intravenous narcotics are often prescribed to minimize pain until mucositis resolves. In some studies, the use of topically applied vitamin E has been found to be helpful to reduce or prevent mucositis [30]. Coconut water, applied topically, has also been reported to relieve mucositis as it promotes wound healing [31].

Constipation is noted as a decrease in the frequency of bowel movements, or hard, dry stools, often accompanied by abdominal discomfort, straining, rectal pain, or cramping. Constipation is often related to decreased gastric motility due to medications (especially vinca alkaloids and narcotics) or may also be caused by tumor compression, electrolyte imbalance, decreased physical activity, changes in appetite, and disruption of normal routine due to hospitalization. Laxatives and stool softeners are often used as prophylaxis against constipation. Drinking warm tea or prune juice and increasing dietary fiber (beans, cereals, and whole-grain crackers) can also help address constipation [32]. It is also important to stay well hydrated by drinking fluids and water throughout the day.

Nursing assessment includes close monitoring of frequency, volume, and consistency of stool output. Report any abnormal signs, such as bleeding or perirectal pain or fissure to the medical team. Interventions include promotion of adequate hydration and a rigorous bowel regime, such as a diet high in fiber and administration of preventative stool softeners or laxatives if constipation is expected before chemotherapy, such as with repeated doses of vincristine [33].

Nausea and vomiting are common and highly distressing side effects of chemotherapy. Acute nausea and vomiting typically begins within several hours of chemotherapy administration and resolves within 24–48 h. However, delayed symptoms can last up to 2 weeks. Poorly controlled nausea may result in complications such as dehydration, poor nutritional intake, electrolyte imbalance, and severe discomfort. Once the cycle of nausea and vomiting has begun, it is difficult to manage. Therefore, prevention before symptoms begin is the most effective approach. Premedication for children who either have a history of nausea or vomiting or who will receive known highly emetic chemotherapy is highly recommended.

Several drug classes of antiemetics are effective. Serotonin receptor antagonists, such as ondansetron and granisetron are highly effective, yet may be limited in availability due to cost. Dopamine antagonists, such as prochlorperazine (Compazine), and glucocorticoids such as dexamethasone, may also be useful in preventing symptoms before chemotherapy is administered. Metaclopramide with diphenhydramine is an effective combination that is often readily available, yet requires monitoring for the risk of dystonic reaction. Nurses are responsible to know the action and side effects of antiemetics and to monitor patients for hyperemesis and dehydration, reporting symptoms to the medical team [33].

Diarrhea is an increase in the quantity, frequency, or fluid content of stool that differs from the usual bowel pattern. Chemotherapy, bowel surgery, radiation therapy, and infection may all be causes of diarrhea [33]. Complications include dehydration, malnutrition, intestinal infection, electrolyte imbalance, and social withdrawal due to disrupted daily routines. Children with severe diarrhea must be closely monitored for signs and symptoms of dehydration and electrolyte imbalance. Nurses must track intake and output carefully and report imbalances to the medical team. Daily weights and careful monitoring of abdominal symptoms and perirectal breakdown are usually indicated. Patients with diarrhea should be isolated until infectious causes can be ruled out. Dietary measures to control diarrhea include eating small frequent low fat snacks, limiting milk products, and eating food at room temperature [32].

Providing children with food and nourishment is a fundamental parental task. In the hospital setting, nourishment may become a difficult issue. Children and adolescents may refuse to eat unfamiliar foods; in addition, chemotherapy and other treatments may change a child’s taste sensations turning formerly favorite foods to unpleasant or unusual tasting. Many treatment-related factors may impact the child/adolescent’s nutritional status, such as type of tumor, nausea/vomiting, constipation, and oral and gastrointestinal toxicities of medications [34].

Children in countries with limited resources may already be malnourished when diagnosed with cancer, although obesity is on the rise and may also impact nutritional status [35]. Poor oral intake increases the risk of dehydration, infection, and gastrointestinal symptoms such as constipation. In settings where food is scarce, the nurse must be particularly observant about what the patient is eating since parents and visitors may also have limited food supplies. Careful evaluation, monitoring, and documentation of the patient’s nutritional status are important upon admission and throughout treatment. It may be necessary to consider supplementing the child’s diet, particularly during induction therapy or in malnourished children with insufficient protein intake. Options may include oral intake of a high-calorie diet with additional protein (such as adding one egg a day or supplements such as Plumpy Nut), nasogastric enteral feeds, or total parenteral nutrition [36, 37].

Parents must be educated about safe storage and handling of foods during cancer treatment, such as washing fruits and vegetables before eating. They should be advised to avoid bringing food prepared under potentially unhygienic conditions into the hospital. Food preparation areas on the pediatric oncology unit stocked with snacks, juice, and bottled water are helpful to parents who want to supplement the child’s hospital diet. Parents are the experts on their child’s food preferences; partnering with parents to address nutritional issues in the hospital will enhance the child’s dietary health [38].

Pain is one of the most frightening and debilitating consequences of childhood cancer. Uncontrolled pain can result in decreased physical activity, poor appetite, fear, loneliness, depression, isolation, and mistrust of the medical team [38]. Pediatric oncology nurses are critical in the assessment, treatment, and evaluation of pain in children with cancer.

Safe administration of chemotherapy is an essential aspect of caring for children, adolescents, and young adults with cancer. The health care team shares responsibility in assuring patient safety by adhering to error prevention practices throughout the chemotherapy process. Pediatric oncology nurses have an important and active role in the patient’s pretreatment evaluation, the administration of chemotherapy and supportive care, as well as post-chemotherapy monitoring. The complexity of chemotherapy and the risk of adverse effects make a process for safe and effective administration of chemotherapeutic agents essential [40]. Ideally, a pharmacist should prepare all chemotherapy under a chemical hood with ventilation systems designed to reduce exposure and protect against toxic fumes. Awareness of the need for trained pharmacists is growing and should be strongly advocated for by pediatric oncology care teams [41].

When a nurse is responsible for preparing chemotherapy, training in chemotherapy preparation and personal safety is necessary. Along with a properly installed, ventilated biosafety hood, adequate personal protection equipment (PPE), which includes chemo safe gowns, disposable gloves, and protective eye gear are critical to minimize personal risk [42]. Adequate staffing of nurses per shift when chemotherapy is being prepared and administered is also essential for patient and nurse safety [43]. The allocation of a designated chemotherapy preparation nurse has been found to improve efficiency, reduce costs, minimize the risk of medication errors, and promote safety for both patients and nurses. The nurse preparing the chemotherapy can serve as the double check to the nurse administering the chemotherapy by verifying the patient name, route, dose, date, and time of chemotherapy medications [44].

Chemotherapeutic agents are administered in a variety of settings, including inpatient units, ambulatory clinics, and in the home. All nurses who administer chemotherapy must be educated about chemotherapeutic agents, the route of administration, side effects, and safe handling practices. A process for assessing the nurses’ knowledge and competency of chemotherapy administration is imperative before they are allowed to administer chemotherapy to a patient.

Pretreatment assessment of the chemotherapy administration process starts with a patient assessment (Table 13.4) including past medical history, allergies, hospitalizations, and current medications. If the patient has received chemotherapy or radiation therapy in the past, it is important to assess for previous use and effectiveness of antiemetics, presence of side effects, and overall tolerability of treatment. This allows the nurse to determine if adjustments should be made for the current chemotherapy administration.