Autologous bone marrow transplants (BMTs) are the most common type of BMT in children. In an autologous BMT the patient is the donor and the recipient of the bone marrow. Children with solid tumors such as neuroblastoma, Hodgkin disease, non-Hodgkin lymphoma, rhabdomyosarcoma, Ewing sarcoma, and Wilms tumor have been treated with autologous BMTs. Peripheral stem cell transplants (PSCTs) are a type of autologous transplant that differ from autologous BMTs only in the method of collection of the stem cells. Stem cells are the origin of all blood cells--white blood cells, red blood cells, and platelets. When bone marrow is harvested, it is the stem cells that are used to rescue the patient following high doses of chemotherapy. Once the stem cells are infused they migrate to the bone marrow where they mature to become white blood cells, red blood cells, and platelets.
Children who receive a PSCT receive a growth factor to stimulate the production of many stem cells following chemotherapy. Injections of the growth factor are given daily until the child's white blood cell count is high enough to harvest the stem cells. The child then comes to the health care facility and is connected to an "apheresis" machine. This machine filters out peripheral stem cells from whole blood, returning the remainder of the blood cells and plasma to the child. This process of collection may be done more than once to reach a critical mass of cells. The peripheral stem cells are then frozen until the patient is ready for the PSCT.
Pre-transplant nursing care for children receiving peripheral stem cells should include education regarding the daily injections of growth factor; education regarding the apheresis process; explanation of BMT unit policies on visitation; high dose chemotherapy protocol; peripheral stem cell infusion; and routine care during the hospital stay including bathing, mouth care, school, free time, physical therapy, and meals.
Nursing care of the child receiving a PSCT is similar to that
provided for a child receiving an autologous BMT. All children will undergo a
prolonged period of pancytopenia. The risk of infection is high for children
receiving PSCTs. Nursing care should include assessing the child's skin
integrity and oral mucosa every eight hours; monitoring vital signs every four
hours; maintaining isolation; and ensuring the child bathes daily and performs
mouth care four times a day. There is also a potential for bleeding due to
thrombocytopenia. Nursing care should include use of soft toothbrushes; testing
urine, emesis, and stool for blood; and assessing skin for ecchymosis,
petechiae, and prolonged bleeding from venipuncture. To reduce the distress of
invasive procedures, such as the daily injections of growth factors, the local
anesthetic, EMLA, should be applied to the site (Wong, 1995).
[Guidelines
on using EMLA].
Bone marrow transplantation and peripheral blood stem cell transplantation, Aug. 1995, Leukemia Society of America.
Cooper DL: Principles and practice of peripheral blood stem cell transplantation, Oncology Updates 8:1-12, 1994.
Stewart SH: Bone marrow transplants: A book of basics for patients. Highland Park, IL, 1992, EMT Newsletter.
Wong D: Overcoming "needle phobia" with EMLA, Am J Nurs 95(2): 24, 1995.
See Chapter 36 in Nursing Care of Infants and Children, 5th and 6th editions.
See Chapter 26 in Essentials of Pediatric Nursing, 5th edition.
March 15, 2002