Module 4 Caring for Children with Alterations in Hematologic

1. Module 4 Caring for Children with Alterations in Hematologic/Immunologic Chapter 26

2. The Hemopoietic System Anemia's What causes alterations in hemopoietic/immunological systems? acute blood loss long-term nutritional deficit acute/chronic systemic disease genetic disorders

3. Assessment - Child�s History Dietary nutritional assessment food choices low iron content Frequent infections Exercise/play tolerance level of frustration 02 capacity attention span Pain Bleeding that is difficult to control

4. Physical Exam Integumentary petechiae ecchymosis hematomas Color pallor look at conjunctiva, sclera, mucous membranes jaundice

5. Physical Exam Cardiovascular capillary refill tachycardia arrhythmias peripheral pulses Respiratory signs of CHF

6. Physical Exam Musculoskeletal joint enlargement Lymphatic lymph node swelling G.I tenderness hepatosplenomegaly

7. Screening and Diagnostic Tests CBC RBC�s - #of red blood cells hemoglobin/hematocrit MCV - mean corpuscular volume reflects average size of each RBC - microcytic, normocytic or macrocytic MCH - mean corpuscular hemoglobin the average hemoglobin content in each RBC

8. Screening and Diagnostic Tests Platelet count - ability to clot Reticulocyte count - # of young RBC�s WBC need to look at differential neutrophils - fight bacterial infection bands - immature neutrophils lymphocytes - help develop antibodies and delay hypersensitivity monocytes - clean up eosinophils - increased in allergic responses basophils - allergic responses

9. Screening and Diagnostic Tests Other Labs Serum Ferritin - Iron storage protein measured to assess the adequacy of iron reserves TIBC - total iron-binding capacity amount of available transferrin for binding more heme FEP - free erythrocyte protoporphyrin iron combines with proptoporphyrin to form heme

10. Screening and Diagnostic Tests Peripheral blood smear abnormalities in shape and size of cells Occult blood looking for bleeding Hemoglobin electrophoresis differentiates the various types of hemoglobin Bone marrow aspiration look at development of blood cells site posterior iliac crest

11. Red Blood Cell DisordersAnemia Two Categories 1. Those resulting from impairment in production of RBCs 2. Those resulting from increase destruction or loss of RBCs Clinical sign/symptoms related to the decrease in the oxygen-carrying capacity of the blood

12. AnemiaSigns/symptoms Initially are non-specific pallor irritability weakness anorexia decreased exercise tolerance lack of interest in surrounding Mild anemia asymptomatic or symptoms on exertion

13. AnemiaSigns/symptoms Severe Anemia skin is waxy, sallow in appearance cardiac decompensation and CHF Hgb 7-8g/100ml cardiac compensatory adjustments occur pallor of the skin and mucous membranes

14. AnemiaSigns/symptoms Sign of CHF tachycardia tachypnea SOB dyspnea edema hepatomegaly Infants may exhibit few s/s with a hgb 4-5g/100ml

15. Anemia - Nursing Care Assessment v/s, I & 0 urine dip stick urine specific gravity stool occult blood examine skin for signs of petechiae

16. Anemia - Nursing Care shock tachycardia pallor agitation thirst confusion Nutritional Needs calorie count daily wt.

17. Anemia - Nursing Care Food high in iron - especially with iron deficiency anemia green leafy vegetables eggs, organ meats cereals fortified with iron Hydration - especially with sickle cell

18. Anemia - Nursing Care Infections major problem with blood dyscrasias handwashing protective isolation v/s. - esp. the temp rest periods meet needs promptly good skin care Anxiety r/t hospitalization Transfusions - blood and or platelets

19. Iron Deficiency Anemia Most common between the ages of 12-36 months and growth spurt in adolescence Possible causes insufficient supply of iron impaired absorption of iron Assessment detailed diary of dietary foods and amounts

20. Iron Deficiency Anemia Labs CBC, Serum Ferritin, TIBC, FEP, Reticulocyte count Treatment dietary education and change be sensitive to cultural foods and beliefs changes take time and need support decrease milk intake

21. Iron Deficiency AnemiaTreatment Iron supplement therapeutic levels give between meals with orange juice stains teeth - temporary stools changes - tarry green poisonous in improper dosage

22. Red Blood Cell DisordersSickle Cell Anemia Hereditary disorder characterized by abnormal type of hemoglobin - Hgb S Sickling phenomenon - crisis takes place when oxygen tension in blood is lowered triggers infection dehydration exposure to cold stress - physical or emotional

24. Sickle Cell Anemia Sickling RBCs sickle and clump together under low oxygen tensions causing a jamming effect in small vessels leading to tissue ischemia Signs/symptoms Infancy frequent infections failure to thrive

25. Sickle Cell AnemiaSigns/symptoms irritability pallor hepatospenomegaly jaundice growth retardation Older Children pain joint, back and abdominal

26. Sickle Cell AnemiaSigns/symptoms nausea and vomiting frequent infections esp. respiratory tract All areas of the body are involved soft tissue swelling joint swelling - pain organs suffer serious complications from tissue ischemia leading to infarction liver failure kidney failure

27. Sickle Cell AnemiaTreatment rest to decrease oxygen consumption pain management hydration oxygenation protection from infection prophylactic penicillin acute infection IV antibiotics

28. Sickle Cell Anemia Nisha is a 14 yr. Old, lives her her mother and grandmother. Is enjoying her summer breaks, likes softball, shopping with girlfriends and movies. Mom brings her into the hospital c/o severe pain following pitching 7 innings in a softball game. VS T 99.7 HR 110, RR 30, B/P 96/70, Sat 89% Wt. 50Kg CBC wbc 12,000 hgb & hct 9 and 24, platelet 140,000 What are your impressions of these values?

29. Discuss the pathophysiology of sickle cell anemia What happens in crisis? What other assessment data would be helpful in developing her nursing care plan? What are your nursing diagnosis?

30. What do you think about the following orders? VS q4 hr, notify if T >100.4 Reg dt B/R with BSC CBC with diff in am, UA and C/S, CXR D5% 1/2NS at 175ml/hr PCA - MS 1.5mg/hr with 1mg q 8min prn Tyl 650mg po q4hr prn T >100.4 02 2L keep sat >94%

31. What nursing interventions are appropriate in meeting Nisha needs? Four days later, pain is at 1/10, Nisha is up in chair, sitting quietly, sad facial expression. How will you approach her? What are her teaching priorities for discharge?

32. Hemophilia Group of bleeding disorders inherited deficiency of clotting factor Signs and Symptoms bleeding anywhere from or in body hemarthosis hematomas excessive bruising, minor injury hematuria

33. Hemophilia Treatment replace clotting factor prevent bleeding RICE Prognosis no cure control symptoms - normal life span

34. Neoplastic DisordersLeukemia Malignancy of unknown cause affecting the blood-forming organs Acute Lymphocytic Leukemia most prevalent in children unrestricted proliferation of immature WBCs Signs/symptoms fever abdominal pain

35. LeukemiaSigns/symptoms bone pain anorexia lethargy, malaise pallor hepatoplenomegaly lymphadenopathy petechiae, ecchymosis

36. Leukemia 4 major problems associated with diagnosis and treatment of leukemia 1. Anemia 2. Infection 3. Hemorrhage 4. Leukemic invasion CNS involvement increased ICP, meningeal irritation, n/v, lethargy, H/A, seizures

37. LeukemiaDiagnosis Established by a stained peripheral blood smear and bone marrow aspirate cells in the marrow are precursor cells to those in the periphery normal marrow elements are replaced with abnormal cells

38. LeukemiaTreatment Chemotherapy set protocols common side effects anorexia, n/v alopecia infection bone marrow depression mucous membrane ulceration

39. LeukemiaNursing Care High Risk for Infection reverse isolation skin care nutrition sterile technique central line - port-a-cath labs ANC (absolute neutrophil count) multiple #WBC by % of neutrophils

40. LeukemiaNursing Care PC: Hemorrhage assess skin for bleeding dip stick urine guaiac stool guaiac emesis bleeding gums v/s monitor labs

41. Nursing Care Hematological Precautions no rectal temps no rectal medications no injections no visits to playroom labs platelet count

42. Nursing Care Assess for complications of anemia bleeding CHF hypotension changes in behavior

43. LeukemiaNursing Care Altered Nutrition small frequent meals foods child likes and are nutritious attractively served keep child company while eating clean environment good oral hygiene

44. LeukemiaNursing Care Anxiety: child and family therapeutic communication good listener encourage family to help allow them some control use play therapy anticipate grieving

45. Leukemia Case Study Ashlee is 4-yr old who lives with her parents and 2 older siblings. She is very active, plays outdoors, rides tricycle, family�s jungle gym and goes to pre-school. During the past 2 months Ashlee has been less active and begun to take 1-2 naps in the afternoon. Mom thinks she looks pale, takes her temperature, it is elevated so they go to the pediatrician. She has an upper respiratory tract infection, Dr. is concerned about possible leukemia so she is admitted to the hospital.

46. What diagnostic tests would your expect to be ordered? Admission vital signs and labs are as follows: T 100.4, HR 120, RR 28, B/P 100/60 CBC RBC 4.6 WBC 4,000 Hgb & hct 11 and 31 Platelets 130,000 Differential neutrophils 1,600 monocytes 290 lymphocytes 1,200 eosinophiles 120 basophiles 30

47. Tests confirm a diagnosis of acute lymphocytic leukemia, what is this? Ashlee�s Mom is crying at the bedside, �how can God let this happen� �how can I make it go away.� How will you respond to her? What are the nursing priorities of care for Ashlee? Discuss the appropriate nursing interventions. Discuss the factors that affect Ashlee�s prognosis.

48. Chemotherapy regimen is started Zofran 2.5mg IV prior to chemo and then q4hrs for 24 hrs. Dexamethasone 16mg IV prior to chemo Ativan 1mg IV q4hrs for break thru nausea Discuss Ashlee�s level of growth and development and how her treatment may impact this. How can you work with Ashlee�s parents to help prevent complications associated with her growth and development?