A student nurse plays a major role in maintaining the sound health of an individual and the family along with the other health care teams. In instances when there is a disturbance in the normal optimum level of functioning of these people, he or she has to take into consideration many things first before deciding what proper and necessary nursing intervention the individual or the family will need to restore his/her/their health.
This essay has the aim of discussing the disease Acute Lymphoid (Lymphocytic or Lymphoblastic) Leukemia or ALL in middle childhood. It will discuss the effect of the condition on the physical, cognitive, social developments and on the activities of daily living of a child who belongs to a family headed by a single parent with more than one child.
In this essay, I have chosen a child in his middle childhood as my patient because this is the age when growth and development increasingly influence behavior, or the stage of the peak of the development of physical, cognitive, social aspects and communication skills (Kozier, 2004), meaning the possibility of the absorption and putting into practice the health teachings given by the nurse is highly attainable. I have chosen the health challenge of possessing Acute Lymphoid (Lymphocytic or Lymphoblastic) Leukemia or ALL because, amongst the other choices, I believe it’s one of the least reversible diseases, therefore should be addressed more to ensure the patient’s quality of life while he’s still living.
A brief overview of the chosen health challenging condition
Leukemia is defined as the condition when bone marrow becomes cancerous, and the huge number of WBC are turned out rapidly (Marieb, 2003, p. 312). Acute Lymphoid (Lymphocytic or Lymphoblastic) Leukemia (ALL) is defined as the proliferation and distortion of white blood cells or leukocytes. Currently considered as the number one cause of cancer in children (Pillitteri, 2007, p. 1696), it is believed to be having a percentage of 75% as against all other leukemia. Other forms of leukemia are cited:
The disease is idiopathic, meaning the disease’s cause is unknown. Predisposing factors include radiation (x-ray exposure while in utero and during childhood), exposure to chemicals and genetic factors like Down Syndrome (chromosomal abnormality wherein there is an extra chromosome 21), and Fanconi’s Syndrome (a condition wherein there are several congenital abnormalities, some which are skeletal and renal abnormalities, hypogenitalism and short stature) (Pillitteri, 2007)
Impact of leukemia on the child’s physical development
The signs and symptoms of the disease include pallor skin, low-grade fever, lethargy, petechiae, bleeding from oral mucous membranes, easy bruising. Due to splenomegaly (enlargement of the spleen) and hepatomegaly (enlargement of the liver), there is an occurrence of abnormal cells, abdominal pain, vomiting, and anorexia. There is also bone and joint pain due to the invasion of abnormal lymphocytes to the bone periosteum.
Central Nervous System effects are headaches and unsteady gait. Other signs and symptoms experienced by the patient are painless, generalized lymphadenopathy on the submaxillary and cervical nodes. Laboratory diagnosis reveals normal or slightly decreased WBC with very immature blast cells. Platelets and hematocrit fall, RBC are of normal size (normocytic) and color (normochromic) (Pillitteri, 2007, p. 1697).
Chemotherapy is the leading treatment for leukemia. It is done for complete obliteration of leukemia cells (induction phase), avoidance of leukemia cells to spread in the CNS (sanctuary/consolidation phase), administration of other intensive therapy, and maintenance of the obliteration of the leukemia cells (maintenance phase) (Pillitteri, 2007). Drugs associated with chemotherapy are vincristine (for acute lymphoblastic and other leukemia), prednisone (for severe inflammation and immunosuppression), L-asparaginase (for acute lymphocytic leukemia with other drugs, sole induction drug for acute lymphocytic leukemia), doxorubicin (for acute lymphoblastic and myeloblastic leukemia) and methotrexate (for acute lymphocytic leukemia) (Nursing 2006 Drug Handbook, 2006).
Leukemia is attempted to be cured at an early stage as it causes serious complications. Some of these are CNS-related effects like blindness, hydrocephaly, recurrent seizures, nuchal rigidity, headache, irritability, and papilledema. Renal malfunctions and testicular abnormalities are also at risk (Pillitteri, 2007).
Since children diagnosed with this condition have dysfunctional WBC, it is important to ensure that they are monitored for possible infections because they are immunosuppressed. Other blood-related risks, like contact plays that could cause easy bruising of the child, have to be closely observed. Their CBC has to be monitored regularly to determine any fluctuations in their blood components (Pillitteri, 2007).
Leukemia has a strong impact on a child’s physical development. Everything about the physical development of a child slows down as the treatments are invasive in their very sense. The health condition and treatments also can kill rapidly growing cells that’s why there are distinct growth and development effects on the child. One example is their thyroid abnormalities. They often are easy to get tired (The Leukemia and Lymphoma Society).
Their metabolism is altered that they are diagnosed to have severe weight loss (International Journal of Cancer). However, due to the treatments, they are undergoing (for example, their medicines associated with chemotherapy), they tend to appear bloated. Another is their susceptibility to infertility. With this effect, it is evident that their hormones are imbalanced, or their gonads aren’t developed enough that they tend to make the child unable to conceive in the future. Aside from this, hearing loss is another concern. They are also prone to stroke. This is associated with the CNS effect of leukemia.
They are prone to having ischemia and this is considered to be a major problem. Children with leukemia are also prone to be developing other cancer-related effects, like the possibility of acquiring other kinds of tumors related to cancer. Since cancer cells are rapidly growing, it’s not unusual for them to develop other cancerous diseases. Given these effects, their chances of survival are depleted. When their cells aren’t mature and developed enough to withstand other diseases’ complications, they aren’t far from losing their lives (The Leukemia and Lymphoma Society).
Impact of leukemia on the child’s cognitive development
In the aspect of cognitive development, they manifest some learning disabilities like problems solving mathematical problems, recognizing and dealing with visuospatial relationships, and maintaining concentration and usual attention span. Given these effects, we’d realize that they are incapable to go along with children of their ages because their cognitive skills aren’t growing in a parallel manner. In the terms of language, their handwriting reading, and spelling skills are also impaired.
They also have difficulties in processing information, planning, and organizing which are commonly accomplished by a child in his middle childhood (The Leukemia and Lymphoma Society). Middle childhood is one of the most critical stages in terms of cognitive development (Potter and Perry, 2001), and any alteration to the normal learning skills could result in a lifetime effect on the child if he ever survives.
Anxiety is one of the possible effects of leukemia, on the child and his/her family. It is exemplary for my child and family assessment because the child belongs to a family with a single parent as the head of the family. The single parent may develop mild anxiety because of the fear of the loss of life, and of course, on the fact that the treatments may not always be available because of the scarcity of budget. Anxiety may also be related to the fact that the rest of the children in the family may be left out because all attentions are on the child with leukemia. There is also a possibility that the family may develop anxiety over the procedures alone, because the person who will undergo is part of their family, and is still a child.
For instance, like this, the student nurse’s responsibility is to explain briefly and simply to the child and his/her family the diagnostic and therapeutic procedures to reduce anxiety and provide support (Pillitteri, 2007). It is important to fully orient the child before he undergoes chemotherapy because, during this procedure, the nurse must understand that just looking at the size of the needle that will be used is enough to scare the child (Pillitteri, 2007, p. 1119), that’s why the providence of support and the assurance that the procedure will help him restore his health is of great importance.
Impact leukemia of leukemia on the child’s social development
In the sense of their social development, they are now undergoing Erikson’s Psychosocial school-age developmental task which is Industry (beginning to create, develop and manipulate) vs. Inferiority (loss of hope, sense of being mediocre) (Kozier, 2004, p. 354). Children at this stage are now learning to do things well, especially in school. Their socialization with their peers happens mostly at scouts, camps, and other extracurricular activities provided by their school. They are mostly interested in competitive play, wherein there is a one-on-one competition. Children at this stage prefer to have their room and own dresser at home to make them independent and prepare them for adolescence (Pillitteri, 2007, pp. 917 – 919).
However, children with leukemia may have impaired social skills and they may also be limited to some social interactions. As we have discussed, children diagnosed with this condition have dysfunctional WBC, meaning their immune system isn’t functioning correctly.
It is important to protect them from infection, most importantly from communicable diseases, and with this, their will to mingle with other children, most importantly with strangers is usually not followed. They may not be able to do things their way and learn from other people because they are closely guarded against these instances. It is also important to limit them from participating in contact sports because of their susceptibility to hematoma. Their wishes of doing the sports children of their age are participating in are usually not granted.
Given these situations, the student nurse’s role is first centered on establishing rapport and gaining the trust of the child. Middle childhood is the stage of the development of self-concept, wherein interaction with others, especially with peers in the issue of learning, self-concept, and body image is of great importance (Potter and Perry, 2001, p. 548). Since these social developments aren’t usually given to the child, they may have untoward reactions over strangers at the first meeting.
The student nurse’s roles mentioned above are important in communicating with the child in his middle childhood regarding his health issues and along with those, the nurse should consider talking to the child at his eye level to decrease intimidation and including him in the conversation when communicating with the parents (Kozier, 2004, p. 426).
Impact of leukemia on the child’s activities of daily living
We have talked about the effects of leukemia on the child’s physical, cognitive and social development. It’s also important to know the health condition’s effects on the child’s activities of daily living.
Since the child belongs to a family headed by a single parent with more than one child, there is a great possibility that he is closely monitored compared to the rest of the children in the family. As we have discussed earlier, he has problems and possibly, complications due to his health. It is only important to guard the child at all times since he isn’t able yet to restrict him from the situations that should be watched out for. He may not be able to do simple tasks alone because we’ll never know when he might faint due to blood-related problems. He also may not be able to mingle the usual way even to his siblings for the aim of protecting him from all sorts of infections.
In connection with these, it is important to help the child achieve a sense of self-esteem as he may lose this in the process of limiting his activities. The nurse’s role in this situation is to never leave the child is doing his activities of daily living, but allowing him to do things on his own. For example, if the child wishes to slice an apple, we may go along with him and accompany him in the kitchen, let him do the slicing yet keeping in mind to give him a plastic knife able to slice foods. This way, we can have him regain confidence and independence without getting far from our roles
Challenges for the child and family
The acceptance of chemotherapy as a treatment for the disease is a major challenge. The child and the family need to deal with numerous effects of allowing the patient to undergo the treatment. For the nurse to understand the challenge and to apply proper nursing intervention for the problem, he/she must assess the child and the family’s understanding of the treatment and their anxiety level. These factors have to be assessed because it will help the nurse understand that she has to explain, on the child and family’s level of understanding, chemotherapy as a treatment for their ill family member (Pillitteri, 2007).
Anxiety level has to be reduced, especially on the child’s part, because this will help in the optimum level of cure. For example, if the child expresses anxiety on the third treatment, the student nurse’s role is to reorient the child with the fact that he has already undergone the treatment, and therefore the same care and support given by her and his single parent along with his other siblings are always available. Aside from this, the student nurse may also provide the child entertainment first before the procedure by allowing him to play, watch or listen to music first so he could retain in his mind the joy of playing instead of the fear of the procedure.
Understanding hair loss and its causes, as a side effect of chemotherapy, is also a challenge for the child and his family. A child in middle childhood learns mostly outside from home, usually through his peers from the neighborhood and his school. As he goes through the therapy without absenting himself from his usual activities of daily living, he and his peers would notice his hair loss, and this should be properly addressed or explained by the nurse.
For the nurse to succeed in her health teaching regarding hair loss, she has to review to the child and the family the structure and functions of hair, and then explain why it is possible to happen for a person undergoing the treatment. This greatly helps in preserving the self-esteem of the child (Pillitteri, 2007). The student nurse may want to consider practical ways such as shaving off the hair of the child so the child will not have the feeling of intimidation by the sight of unequal or unbalanced hair loss.
She may be as creative as having the child wear wig to look natural, wear a scarf, hat, cap, or any other form of headdress so the child could still have a cheerful aura amidst his hair loss. The student nurse can be as creative as she can as long as it is for the good of the child. I even watched from a TV series an episode wherein the cancer patient’s support group, along with the health care team, all had their hair shaved off to have the patient feel that he “belongs”, and that his condition is not a that big deal in deviation with normal at all.
Another challenge for the child and consequently, the family, is the possibility of a feeling of reduced self-esteem and competence occurring on the child. The child isn’t far to feel this deprivation because he is now monitored and taken care of more than he ever was before he became ill. To prevent this from happening, the child has to be assisted in performing again the activities of daily living he does before he became ill.
Allowing the child to do activities independently with close supervision allows him to regain self-confidence, self-esteem, and competence and lets him understand that his disease will not prohibit him from doing the things that aren’t hazardous to his current condition and make him happy (Pillitteri, 2007). As we have discussed, the student nurse may want to consider letting the child still do his usual activities of daily living but with close supervision.
The student nurse may also be a substitute playmate of the child so he could still have his will to play. The kinds of play that a student nurse may want to play along with the child are mostly indoor games like scrabble (it is advisable because the game tends to expound the cognitive development of the child), chess (same as with scrabble), monopoly (this could have the child broaden his imagination that he may feel that he’s actually out from home and enjoying in the streets, as per the game’s description), and not so extraneous games like tan man, and charades (Pillitteri, 2007).
Professional and ethical issues that a student nurse needs to consider
One of the major ethical issues that a student nurse must consider is the Principle of Autonomy of the child. Autonomy is the right of the person to decide on his own, especially about issues about his health. A nurse, along with the family, has to fully examine the child’s opinion regarding the treatment he is about to undergo, because his body is the physical entity that is subjected in these instances, and if any procedure, especially the invasive ones, are a threat to the child, he/she has the right to be heard and be followed accordingly (Valentine, 2007). One of the basic rights of the child is their right to be heard or their right to express themselves (UNICEF).
This child right wants to make explicit the fact that on issues related to the child’s physical being, he has to be taken into consideration when deciding about the procedures that will be executed about his current health condition. A student nurse’s role in this issue is to briefly examine the child’s and the family’s decisions about the decision that the child has to make.
To help us understand the issue of the child’s autonomy and to have a brief knowledge regarding this important decision-making process, it is important to cite a real-life story that’s related to this topic. Happened in November last year, a 14-year old boy died of leukemia in Mount Vernon, Seattle. His death circulated on the issue of cultural diversity (which will be discussed further later) related to how they accept treatments like a blood transfusion.
According to the news, the boy rejected blood transfusion as a treatment due to his adherence to his religion, Jehova’s Witness. His wish to reject the treatment was affirmed, and blood transfusion was never done to him (Ostrom, 2007). Based on this news, we could already see how big the impact of the child’s decision is on his condition. It is then important for the student nurse to fully understand the principle of the right of autonomy and further review transcultural nursing.
Other issues to be considered by the nurse are the cultural variations and religious beliefs in terms of the people’s approach to various treatments. As we all know, chemotherapy is currently the sole treatment for leukemia. Yet this should not be insisted to the child and the child’s family. Their complete approval of having the child undergo the treatment has to be obtained with necessary consent from the family. In association with this, their culture will affect them so much their decision.
That’s why their culture has to be considered to exhibit another principle, the Principle of Respect. Cultural variations and religious beliefs affect a lot the way people accept blood transfusion as another way to treat children with ALL. For instance, the religion Jehova’s Witnesses don’t allow blood transfusion to be undergone by their members. Yet, at some point, it happens when the patient won’t need a blood transfusion but still, they do survive (Takeuchi, 1999). The student nurse’s role is to assist the family in times of relaying concerns to or from the family. In times when the family has questions or disproves the treatments, the student nurse should report it to her clinical instructor so that her immediate supervisors will act accordingly.
The least that a student nurse could do is to modify the anxiety level of the child and the family because alleviating anxiety might be a solution to any preliminary rejections of the treatments. The student nurse must always take into consideration that the single parent of the child with leukemia has his/her mind scattered, probably because of the financial issues and even the fact that the parent isn’t only a parent to the child with leukemia but other children as well.
The student nurse has to keep in her mind that everything that she has learned in school, especially the principles circulating her profession, will all be used inevitably. She has to memorize by heart the basic interventions on different problems. And most importantly, she has to be open and critical to the basic things that should be considered at all times. For example, she should take note of the family background of the patient, the age, the culture, the health condition, and many other things.
As I have mentioned in the introduction, the very aim of giving priority care to the child with leukemia is to let him live his life happily as he already has little chance of surviving. It is in these cases when we’ll be able to see the importance of considering various professional and ethical issues. For example, it’s not enough to advise the family what they need to do for their family member to sustain his / her life. We have to be as broad-minded as possible to be able to achieve an optimum level of treatment. This is when transcultural nursing comes of great importance: when we start to explore the norms of other cultures but still clinging to the aim of our profession: providing care and helping patients sustain their lives (Leininger, 2002).
As student nurses, we are constantly faced with different obstacles and dilemmas and there is nothing to do but to broaden our minds and consider all aspects of the people we give care to. It’s not enough to function as a nurse. Before meeting the patient, we have to review his/her background as if we’re reviewing for our board exams, so that when it’s finally the time to speak with them, we’d address what is meaningful to them, at the same time meeting our responsibilities as health care providers.
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Leininger, M., McFarland, M. (2002) Transcultural Nursing: Concepts, Theories, Research and Practice. McGraw – Hill Professional.
Marieb, E. (2003) Essentials of Human Anatomy and Physiology. Pearson Education.
Nursing 2006 Drug Handbook 26th Edition. (2006) Lippincott Williams and Wilkins.
Ostrom, C. (2007) Mount Vernon leukemia patient, 14, dies after rejecting transfusions. The Seattle Times.
Pillitteri, A. (2007) Maternal and Child Health Nursing: Care of the childbearing and childbearing family – 5th Edition. Lippincott Williams and Wilkins.
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Takeuchi, S., Utsunomiya, A., Makino, T., Shimotakahara, S., Takatsuka, Y., Kawabata, H., Nakashima, A. (1999) Successful treatment for acute lymphoblastic leukemia without blood transfusion in a Jehovah’s Witness. Wiley – Liss, Inc.
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UNICEF. Child’s rights. 2008. Web.
Valentine, F., Lowes, L., Weston, S. (2007) Nursing Care of Children and Young People with Chronic Illness. Blackwell Publishing.