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

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 Bleed after IM

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?