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Central Venus catheters (CVC’s) such as Hickman lines, will requires a weekly dressing change - where the line will be cleaned, looped and secured. This weekly change helps to reduce the risk of an infected line and prevent the line from being pulled out. In addition the smart sites will also need changing weekly, along with a weekly flushing of 0.9% saline and heparin under a positive pressure, to reduce the risk of the line occluding due to the formation of blood clots. Teaching will also be required on line safety and the importance of having a line safety pack wherever Toby may be. In addition the parents and Toby will be taught about what signs of infection to look out for and they will be advised to not get the site wet. This means Toby will be excluded from swimming at school and it may cause trouble whilst bathing and showering.

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Chemotherapy has a range of side effects which will need management. Side effects include:
.Sickness and nausea-this is managed by anti sickness medication such as ondansatron and cyclizine (oral or IV)
.Compromised immune system-chemo kills off fast growing cells which includes immune cells therefore Toby is more likely to pick up infections than a well child, therefore he should be monitored for high temperatures as this is an indicator for infection
.Hair loss-hair cells are also fast growing cells therefore hair loss will occur, Toby will need to be made aware of this before commencing chemo as it can still come as a shock
.Mucocitis-chemo can cause the lining of the gastrointestinal tract to become sore and inflamed and can therefore cause mouth ulcers and dry lips therefore mouth care is important to manage the symptoms

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- SLHL
- DLHL
- Port
- PICC

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Toby will require an NG tube and so teaching will be required for ph testing, what to do if it is misplaced and the parent may even be trained how to pass an NG if they desire. NG will help short term for children with mucositis that may find it to painful to eat. Long term the NG can be used for oral meds and for nutritional intake when chemotherapy may interfere with the child’s taste and make Toby feel sick and unable to eat.

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DLHL

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https://link.springer.com/chapter/10.1007/978-3-642-46323-5_2
Toby is 8 years old which puts him in the Concrete operational stage according to Piaget’s theory of child development
In this stage children should be able to:
*begin thinking more logically about concrete events
*understand the concept of conservation
*think more logically and organised
Begin using inductive logic
As he is in this stage it is likely that Toby will what to be involved in his care, this should be accomodated and he should be allowed to help get the equipment ready where possible and help do the flushes on his line and NG tube if required.

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NG Tube

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Port

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https://www.nice.org.uk/guidance/csg7
This guideline highlights the need for good shared care in order to enhance survival rates in children.
Neutropina is a common side effect a song a result of chemo therapy and it monitored with frequent blood samples being taken. This is why most children have access so they do not require cannulation every time they need bloods.
Neutropinia leavens the child vulnerable to infection and so before leaving hospital it is important that the parents are trained to look for signs of infection so they can prevent the infection getting too bad by taking their child to hospital quickly should signs of infection develop.