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  1. WILMS' TUMOR (NEPHROBLASTOMA)
    1. Introduction: Wilms' tumor, a malignant tumor of the kidney, is the most common form of renal cancer in children. Peak incidence occurs at 3 years of age, with a slightly higher incidence in boys than girls. Ninety percent of the cases occur unilaterally; the treatment of choice is nephrectomy (and adrenalectomy) followed by chemotherapy and radiation.
    2. Assessment:
      1. Most common sign: abdominal mass (firm, nontender).
      2. Most often first found by parent changing diaper; felt as a mass over the kidney area.
      3. Intravenous pyelogram (IVP), abdominal ultrasound, and CT confirm the diagnosis.
      4. Metastasis occurs most frequently to the lungs: pain in chest, cough, dyspnea.
    3. Analysis/nursing diagnosis: altered urinary elimination (other diagnoses depend on stage of tumor and presence of metastasis—similar to adult with cancer).
    4. Nursing care plan/implementation:
      1. Goal: promote normal urinary function.
        1. Inform family that surgery is scheduled as soon as possible after confirmed diagnosis (within 24–48 hours).
        2. Explain to family that the preferred surgical approach is nephrectomy (and adrenalectomy).
        3. Preoperative: do not palpate abdomen because the tumor is highly friable, and palpation increases the risk of metastasis.
        4. Postoperative nursing care: similar to care of adult with nephrectomy (see Chapter 6. Physiological Integrity).
        5. pillImage  Postoperative care also includes long-term radiation therapy and chemotherapy (actinomycin D, vincristine, Adriamycin; see Chapter 6. Physiological Integrity and Chapter 8. Physiological Integrity).
      2. Goal: discharge teaching to prepare parents to care for child at home.
        1. Teach parents need for long-term follow-up care with specialists: oncologist, urologist.
        2. Answer questions regarding prognosis, offering realistic hope.
          1. Children with localized tumor: 90% survival rate.
          2. Children with metastasis: 50% survival rate.
    5. Evaluation/outcome criteria:
      1. Child is able to maintain normal urinary elimination.
      2. Parents verbalize their understanding of home care for the child.