4 Wilms Tumor (Nephroblastoma) Nursing Care Plans

December 30, 2017

Wilms tumor (nephroblastoma) is recognized as the most common pediatric malignant renal tumor in children. The incidence of Wilms tumor is slightly less frequent in boys than in girls. The average age at diagnosis with unilateral tumors is 41.5 months and with bilateral tumors is 29.5 months. It occurs in association with congenital anomalies and chromosomal abnormalities, such as: aniridia (congenital absence of the iris); hypospadias; cryptorchidism; pseudohermaphroditism; Beckwith-Wiedemann syndrome; Denys-Drash syndrome; Perlman and Sotos’ syndrome. The appearance of the Wilms tumor is usually referred to as the “pushing type” (or adjacent renal parenchyma, enclosed by a distinct intrarenal pseudocapsule).

The most common initial clinical presentation for most children with Wilms tumor is the presence of a firm, non-tender abdominal mass. This initial presentation is usually first noticed by a parent while bathing or dressing the child. Other assessment findings at diagnosis include abdominal pain, gross hematuria, low-grade fever, and hypertension.

The most common sites of metastases of Wilms tumor are the lungs, the regional lymph nodes, and the liver. Histology classifies the tumor into: (1) favorable or unfavorable histology; (2) 3 cell types: triphasic or biphasic; with blastemal, stromal, and epithelial elements; and (3) 10% have anaplastic or unfavorable histologic findings, including anaplastic Wilms’ tumor, clear cell sarcoma of the kidney, rhabdoid tumor of the kidney. Other histologic patterns include: nephrogenic rests, congenital mesoblastic nephroma, and renal cell carcinoma.

An unfavorable histology is associated with a poor prognosis and more extensive chemotherapy. Prognosis is determined by the pathologic staging of Wilms’ tumor, defined by the National Wilms Tumor Study Group. Both the histology classification and the pathologic staging of Wilms’ tumor determine the type and length of time for
administration of chemotherapy agents and radiation treatments.

Nursing Care Plans

The nursing care plan goals for a child with Wilms tumor include: prevention of injury, improved condition of oral mucous membranes, comprehension of the disease and its management, and absence of complications.

Here are four (4) nursing care plans (NCP) and nursing diagnosis (NDx) for Wilms tumor:

Ineffective Protection

Ineffective Protection: Decrease in the ability to guard self from internal or external threats such as illness or injury.

May be related to

Antineoplastic agents
Radiation therapy
Leukopenia, thrombocytopenia, anemia, coagulation

Possibly evidenced by

Altered clotting
Bone marrow suppression
Deficient immunity against infection
Hematuria
Hemorrhagic cystitis
Petechiae, bleeding from nose and gums

Desired Outcomes

Child will be protected from illness or injury.

Nursing Interventions	Rationale
Assess for bleeding from any site and febrile episodes; Monitor WBC, platelet count, hematocrit, absolute neutrophil count.	Provides data about frank bleeding or abnormal blood profiles that contribute to bleeding induced by bone marrow suppression and immunosuppression due to chemotherapy.
Perform handwashing prior giving care, utilize mask and gown when needed, provide a private room, monitor for any signs and symptoms of infection.	Prevents transfer of microorganism to a weakened immune system during chemotherapy if the absolute neutrophil count is less than 1,000/cu mm.
Provides safety measures such as pad sides of bed, use soft toothbrush, apply pressure for 5 minutes after IV administration, avoidance of taking rectal temperatures or performing unnecessary invasive procedures.	Avoids bleeding caused by trauma during the administration of chemotherapy which changes platelet and clotting factor.
Instruct parents and child to avoid exposure to persons having an upper respiratory infection or any illness.	Prevents risk for infection in the highly susceptible child.
Advise parents and child to avoid contact sports, blowing nose hard, and straining at defecation.	Prevents trauma that causes bleeding.
Advise parents to report any fever, behavior changes, headache, dizziness, fatigue, pallor, slow oozing of blood from any area, exposure to communicable diseases.	Signifies an associated abnormal blood profile complication.
Teach and allow for return demonstration of urine and stool testing for blood using dipstick and hematest.	Identifies presence of bleeding in the gastrointestinal or urinary tract.
Administer blood transfusion as ordered for severe blood loss, monitor patency, vital signs, chills, fever, urticaria, rash, dyspnea, diaphoresis, headache during transfusion, and terminate if any of these changes occur.	Replaces blood loss when symptoms of anemia appear (dizziness, pallor, fatigue, increased pulse, and respiration) or when Hct is less than 20% or platelet count less than 20,000/cu mm.