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Identification data
Name : AMANAT
Age : 6 yrs
Sex : male
C.R no : 653475
Bed no/ Ward : 11/Neurosurgical ward
Date of admission : 23/02/11
Diagnosis :Neuroblastoma
Fathers education : illiterate
Fathers occupation :Laboourer
Mothers education : illiterate
Mothers occupation : Housewife
Address : Saharanpur(U.P)
Informant : Mother

CHIEF COMPLAINTS:-
The child is a known case of neuroblastoma and admitted for surgery.
HISTORY OF PRESENT ILLNESS: - The child was apparently well till 4years of age.
Mother noticed swelling in the abdominal and inguinal region, accompanied by fever and loss of
appetite. Initially they took treatment from some local physician with little success. Gradually
the swelling developed in cervical and axillary region also. As the symptoms were not subsiding,
so the patient was reffered to PGIMER by the local practioner.
HISTORY OF PAST ILLNESS: -
No h/o any other significant illness in the past.
PERSONAL HISTORY:-
Antenatal History: Nothing significant during the antenatal period.
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Birth History: FTNVD at local hospital. Cried immediately after birth. Developmental
History: No delay in any milestone. Normal growth and development.
Immunization History: immunized appropriate to age.
FAMILY HISTORY:- No significant family history of genetic disorder present.
Family Tree:





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 :Normal
Height : 87 cm
Weight :11.5 kg
Pulse :88/min
RR :16/min

30yrs

33 yrs

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

SYSTEMIC EXAMINATION:-
Respiratory system:-
RR:16/min
Normal respiration at rest
Bilateral chest clear, air entry equal.

Cardiovascular system:-
HR: 88 bpm, S
1,
S
2
present
CFT:<3sec.
All peripheral pulses are palpable.
Central Nervous system:-
No h/o of seizures. Normal Reflexes.
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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
0
C .Skin dirty. personal hygiene not
maintained.

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

3. Activity Intolerance related to fatigue from tumour 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


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CASE HISTORY ACCORDING TO LITERATURE
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:
o 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).
o 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.
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Other common signs:
o Bowel or bladder dysfunction that results from compression by a paraspinal or
pelvic tumor
o Neurologic symptoms because of compression by the tumor on nerve roots or
because of tumor extension
o Supraorbital ecchymosis, periorbital edema, and exophthalmos that results from
metastases to the skull bones and retrobulbar soft tissue
o Lymphadenopathy, especially in the cervical area
o Bone pain with skeletal involvement
o Swelling of the neck or face, wheezing, dyspnea, and cough with thoracic masses
o Symptoms of bone marrow failure, such as anemia, bleeding, or infection
o General symptoms of pallor, anorexia, weight loss, and weakness with
widespread metastasis
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:
o CT scan of primary site and chest
o MRI areas above diaphragm
o Ultrasound examination
o Liver and spleen scan
Genetic indictors of poor prognosis include n-Myc oncogene amplification, hyperdiploid
karyotype, and chromosome deletion.
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Management
Surgery plays a role in 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),
decarbazine (DTIC), cyclophosphamide (Cytoxan), doxorubicin (Adriamycin), cisplatin
(Platinol), carboplatin (Paraplatin), ifosfamide (IFEX), and Etopside (VP-16).
Influencing factors for prognosis:
Stage of disease the earlier the stage, the better the prognosis
Age infants younger than age 1 demonstrate the best survival
Site of primary tumor children with tumors above the diaphragm appear to do
better than children with abdominal tumors
Pattern of metastasis children 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
Clinical picture
The patient is having a abdominal tumor.
The symptoms present in the patient were loss of appetite,abdominal swelling
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Patient had received a cycle of chemotherapy.
This time is child is admitted for surgery. The surgery planned is EL + proceed. The child
has been posted for consultation with department of pediatric surgery.
Nursing Management
Nursing Assessment
Obtain a history.
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
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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.
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.
REFERENCES
1. Kliegman and et al; Nelson textbook of Pediatrics; 18
th
edition; Vol.2; pages:1067-75.
2. Donna L Wong; Essentials of Pediatric Nursing; 5
th
edition; pages: 1045-47.
3. www.google.com(Neuroblastoma)

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