A 3-year-old child with neuroblastoma is receiving chemotherapy and has developed severe mucositis. The child is refusing to eat and has lost 5% of body weight over the past week. Which nursing intervention should be the priority?
1Encourage the child to eat favorite foods and provide high-calorie snacks throughout the day
2Apply topical anesthetic gel to the oral mucosa before meals and increase fluid intake
3Collaborate with the healthcare team to initiate parenteral nutrition and provide comprehensive oral care✓ 정답
4Administer prescribed antiemetics and offer small, frequent meals of soft, bland foods
해설
Severe mucositis with 5% weight loss indicates nutritional compromise requiring parenteral nutrition for adequate intake and oral care to prevent infection. Other options address symptoms but do not prioritize the immediate nutritional crisis.
Core Nursing ExplanationKey Concept Analysis: This question assesses the priority nursing intervention for a pediatric oncology patient experiencing a severe complication of chemotherapy: mucositis. The core issue is the integration of two critical problems: severe pain and inflammation of the mucous membranes leading to refusal to eat, and the resulting significant nutritional deficit (5% weight loss in a week). In pediatric patients, especially those undergoing cancer treatment, rapid weight loss is a serious concern that can compromise healing, immune function, and tolerance to further therapy. The priority shifts from encouraging oral intake to ensuring the child receives adequate nutrition and calories by an alternative route while managing the painful source of the problem.
Answer Rationale: Key Point! Option ③ is correct because it addresses both components of the crisis comprehensively and in the correct order of urgency. Collaborating to initiate parenteral nutrition (PN) is the priority action to immediately address the nutritional crisis and prevent further catabolism. Concurrently, providing comprehensive oral care is essential to manage the mucositis, prevent secondary infections (like candidiasis), and promote mucosal healing. This intervention aligns with the nursing process by first stabilizing the patient's physiological need for nutrition (Maslow's hierarchy) before focusing on comfort and oral rehabilitation.
Distractor Analysis:
Watch out for confusion! Option ① (Encourage favorite foods/snacks) is a supportive measure for mild appetite loss but is ineffective and potentially cruel for severe mucositis. Forcing oral intake on painful ulcers can increase the child's distress and aversion to food.
Option ② (Topical anesthetic and fluids) addresses the symptom of pain and hydration, which is important, but it does not solve the caloric and protein deficit indicated by the significant weight loss. Fluids alone cannot reverse malnutrition.
Option ④ (Antiemetics and small bland meals) is appropriate for managing nausea and vomiting, a common chemotherapy side effect. However, the primary problem here is painful mucositis, not nausea. The child is refusing to eat due to pain, so antiemetics are not the priority, and oral meals are still likely to be refused.
Related Concepts: This scenario highlights the principle of nutritional support in critically ill children. When oral intake is insufficient (< 50-60% of needs) for 5-7 days, or with rapid weight loss, enteral or parenteral nutrition should be initiated. Mucositis management follows a strict protocol of gentle cleansing (saline or sodium bicarbonate rinses), pain control (topical or systemic analgesics), and infection prevention (antifungal/antiviral prophylaxis as ordered).
Concept Summary
Concept
Key Points
Chemotherapy-Induced Mucositis
Inflammation/ulceration of GI tract mucosa. A dose-limiting toxicity. Managed with oral care, pain control, and nutritional support.
Nutritional Assessment in Pediatrics
Weight loss >5% in a week is significant. Monitor intake/output, growth charts, and serum albumin/prealbumin.
Parenteral Nutrition (PN)
Intravenous nutrition providing calories, protein, fats, vitamins. Used when GI tract is non-functional or resting.
Priority Setting (ABCs with Modification)
Airway/Breathing/Circulation come first. Here, "Circulation" includes fluid/electrolyte balance and nutritional status as a physiological priority.
Side-by-Side Comparison!
Intervention for Mild Appetite Loss
Intervention for Severe Mucositis with Weight Loss
Offer favorite, high-calorie foods.
Initiate alternative nutrition (PN or tube feeding).
Provide nutritional supplements (shakes).
Provide comprehensive, protocol-based oral care.
Encourage small, frequent meals.
Administer systemic pain medication (not just topical).
Manage nausea with antiemetics.
Monitor closely for signs of infection (fever).
Anatomy, Physiology & Pharmacology Points
Mucositis affects the entire mucosal epithelium from mouth to anus. Chemotherapy drugs kill rapidly dividing cells, including cancer cells and the basal cells of the mucosa, leading to breakdown, ulceration, and pain. Parenteral nutrition bypasses the GI tract, delivering nutrients directly into the bloodstream via a central venous catheter to meet metabolic demands.
Memory TipsAcronym: PANIC for Severe Pediatric Mucositis Parenteral Nutrition Initiate
Assess Pain & Provide analgesia
Nutritional deficit is key (5% weight loss)
Infection prevention (oral care)
Collaborate with team (dietitian, MD, pharmacist)
High-Frequency NCLEX Topics
The NCLEX-RN frequently tests priority-setting for pediatric patients with complications. Combining a symptom (pain, refusal to eat) with an objective data point (weight loss, lab value) is a classic way to create a high-level question. Always look for the combination that indicates a systemic or physiological crisis over a localized comfort issue.
Watch Out for Question Variations!
* Instead of "priority intervention," the question could ask for the "priority nursing diagnosis" – the answer would be Imbalanced Nutrition: Less Than Body Requirements.
* The scenario could change to an adult patient with the same issue – the principles (PN for significant deficit, oral care) remain identical.
* It could ask for the "first" action – which might be assessing the severity of oral mucositis and pain level before implementing the collaborative plan for PN.
Nursing Clinical Practice GuideClinical Scenario: You are the nurse caring for Liam, a 3-year-old with neuroblastoma. After his second cycle of chemotherapy, he cries when anything touches his mouth, points to his mouth saying "owie," and has barely touched his food tray for three days. His weight has dropped from 15 kg to 14.25 kg. He is listless and not engaging in play.Nursing Intervention Strategy:
1AssessmentPerform a gentle oral assessment using a penlight. Document the extent of ulceration (using a tool like the WHO Oral Mucositis Scale). Assess pain using a validated pediatric scale (e.g., FACES scale). Accurately calculate the percentage weight loss.
2Collaboration & PlanningImmediately report your findings (weight loss, refusal to eat, pain score) to the physician and clinical dietitian. Advocate for the need for parenteral nutrition. The plan will include: inserting a PICC line for PN, initiating a standardized oral care protocol every 4 hours and after meals, and scheduling systemic analgesic administration.
3Implementation* Oral Care: Use a soft pediatric toothbrush or foam swab with a non-alcohol, non-irritating rinse (e.g., sterile saline or sodium bicarbonate solution). Apply prescribed topical anesthetic (e.g., lidocaine gel) only as directed, typically 15-20 minutes before oral care or attempted feeding, watching for systemic absorption in a small child.
* PN Management: Once ordered, meticulously manage the central line, calculate and verify the PN infusion rate with a colleague, and monitor for complications like infection, hyperglycemia, or electrolyte imbalances.
4Education & EvaluationTeach parents how to perform gentle oral care. Explain the purpose of the IV nutrition. Evaluate daily weight trends, pain control, and signs of oral healing or infection.
Patient Safety and Precautions: Never use alcohol-based mouthwashes or hydrogen peroxide on mucositis, as they can cause further tissue damage and pain. With topical anesthetics, be vigilant for signs of lidocaine toxicity (dizziness, perioral numbness, seizures) in young children. PN is a high-alert medication; strict aseptic technique is mandatory to prevent bloodstream infections.
Nursing Procedure & Medication FlowComprehensive Oral Care for Mucositis:
1. Perform hand hygiene and don gloves.
2. Position the child comfortably, explain steps simply.
3. Gently clean oral cavity with a soft tool and prescribed solution.
4. Apply topical medication if ordered, using a cotton-tipped applicator for precise application.
5. Offer a sip of water if tolerated.
6. Document appearance of mucosa, patient tolerance, and pain score.Parenteral Nutrition (PN) Administration:
* Route: Central venous catheter (e.g., PICC, central line) required due to high osmolarity.
* Rate
Mucositis — Inflammation and ulceration of the mucous membranes lining the digestive tract, from the mouth to the anus, commonly caused by chemotherapy or radiation therapy.
Parenteral Nutrition — Intravenous administration of nutrients, including carbohydrates, proteins, fats, vitamins, and minerals, bypassing the gastrointestinal tract. Used when oral or enteral intake is inadequate or not possible.
Neuroblastoma — A type of cancer that develops from immature nerve cells (neuroblasts), most commonly occurring in and around the adrenal glands or along the spinal cord in the neck, chest, or abdomen. It is the most common extracranial solid tumor in childhood.
PICC Line — Peripherally Inserted Central Catheter; a long, thin tube inserted into a peripheral vein (often in the arm) and threaded until its tip lies in a large central vein near the heart. Used for long-term IV access for medications, fluids, or nutrition.
Nutritional Support — The provision of nutrients by oral, enteral (via tube into the GI tract), or parenteral (intravenous) routes to maintain or restore optimal nutritional status, especially in patients who are unable to meet their needs through voluntary oral intake.