Transcript Document 7386274

Module 4
Caring for Children with
Alterations in
Hematologic/Immunologic
Chapter 26
The Hemopoietic System
 Anemia's
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What causes alterations in
hemopoietic/immunological
systems?
 acute blood loss
 long-term nutritional deficit
 acute/chronic systemic disease
 genetic disorders
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
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Physical Exam
 Integumentary
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petechiae
ecchymosis
hematomas
Color
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pallor look at conjunctiva, sclera,
mucous membranes
jaundice
Physical Exam
 Cardiovascular
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capillary refill
tachycardia
arrhythmias
peripheral pulses
 Respiratory
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signs of CHF
Physical Exam
 Musculoskeletal
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joint enlargement
 Lymphatic
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lymph node swelling
 G.I
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tenderness
hepatosplenomegaly
Screening and Diagnostic Tests
 CBC
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RBC’s - #of red blood cells
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hemoglobin/hematocrit
MCV - mean corpuscular volume
 reflects average size of each RBC - microcytic,
normocytic or macrocytic
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MCH - mean corpuscular hemoglobin
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the average hemoglobin content in each RBC
Screening and Diagnostic Tests
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Platelet count - ability to clot
Reticulocyte count - # of young RBC’s
WBC
 need to look at differential
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neutrophils - fight bacterial infection
 bands - immature neutrophils
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lymphocytes - help develop antibodies and
delay hypersensitivity
monocytes - clean up
eosinophils - increased in allergic responses
basophils - allergic responses
Screening and Diagnostic Tests
 Other Labs
 Serum Ferritin - Iron storage protein
 measured to assess the adequacy of iron reserves
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TIBC - total iron-binding capacity
 amount of available transferrin for binding more heme
FEP - free erythrocyte protoporphyrin
 iron combines with proptoporphyrin to form heme
Screening and Diagnostic Tests
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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
Red Blood Cell Disorders
Anemia
 Two Categories
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1. Those resulting from impairment in
production of RBCs
2. Those resulting from increase
destruction or loss of RBCs
 Clinical sign/symptoms
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related to the decrease in the oxygencarrying capacity of the blood
Anemia
Signs/symptoms
 Initially are non-specific
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pallor
irritability
weakness
anorexia
decreased exercise tolerance
lack of interest in surrounding
 Mild anemia
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asymptomatic or symptoms on exertion
Anemia
Signs/symptoms
 Severe Anemia
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skin is waxy, sallow in appearance
cardiac decompensation and CHF
 Hgb 7-8g/100ml
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cardiac compensatory adjustments occur
pallor of the skin and mucous membranes
Anemia
Signs/symptoms
 Sign of CHF
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tachycardia
tachypnea
SOB
dyspnea
edema
hepatomegaly
 Infants may exhibit few s/s with a
hgb 4-5g/100ml
Anemia - Nursing Care
 Assessment
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v/s, I & 0
urine
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stool
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dip stick urine
specific gravity
occult blood
examine skin for signs of petechiae
Anemia - Nursing Care
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shock
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tachycardia
pallor
agitation
thirst
confusion
 Nutritional Needs
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calorie count
daily wt.
Anemia - Nursing Care
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Food high in iron - especially
with iron deficiency anemia
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green leafy vegetables
eggs, organ meats
cereals fortified with iron
Hydration - especially with
sickle cell
Anemia - Nursing Care
 Infections
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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
Iron Deficiency Anemia
 Most common between the ages of 12-36
months and growth spurt in adolescence
 Possible causes
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insufficient supply of iron
impaired absorption of iron
 Assessment
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detailed diary of dietary foods and amounts
Iron Deficiency Anemia
 Labs
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CBC, Serum Ferritin, TIBC, FEP, Reticulocyte
count
 Treatment
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dietary education and change
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be sensitive to cultural foods and beliefs
changes take time and need support
decrease milk intake
Iron Deficiency Anemia
Treatment
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Iron supplement
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therapeutic levels
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give between meals with
orange juice
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stains teeth - temporary
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stools changes - tarry green
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poisonous in improper
dosage
Red Blood Cell Disorders
Sickle Cell Anemia
 Hereditary disorder characterized by
abnormal type of hemoglobin - Hgb S
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Sickling phenomenon - crisis
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takes place when oxygen tension in
blood is lowered
triggers
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infection
dehydration
exposure to cold
stress - physical or emotional
Sickle Cell Anemia
 Sickling
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RBCs sickle and clump together
under low oxygen tensions causing a
jamming effect in small vessels
leading to tissue ischemia
 Signs/symptoms
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Infancy
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frequent infections
failure to thrive
Sickle Cell Anemia
Signs/symptoms
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irritability
pallor
hepatospenomegaly
jaundice
growth retardation
 Older Children
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pain
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joint, back and
abdominal
Sickle Cell Anemia
Signs/symptoms
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nausea and vomiting
frequent infections
 esp. respiratory tract
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All areas of the body are involved
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soft tissue swelling
joint swelling - pain
organs suffer serious complications from tissue
ischemia leading to infarction
 liver failure
 kidney failure
Sickle Cell Anemia
Treatment
 rest to decrease oxygen consumption
 pain management
 hydration
 oxygenation
 protection from infection
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prophylactic penicillin
 acute infection
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IV antibiotics
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.
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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?
 Discuss the pathophysiology of sickle cell
anemia
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What happens in crisis?
 What other assessment data would be helpful
in developing her nursing care plan?
 What are your nursing diagnosis?
 What do you think about the following orders?
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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%
 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.
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How will you approach her?
 What are her teaching priorities for
discharge?
Hemophilia
 Group of bleeding disorders
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inherited
deficiency of clotting factor
 Signs and Symptoms
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bleeding anywhere from or in body
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hemarthosis
hematomas
 excessive bruising, minor injury
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hematuria
Hemophilia
 Treatment
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replace clotting factor
prevent bleeding
RICE
 Prognosis
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Bleed after IM
no cure
control symptoms - normal life span
Neoplastic Disorders
Leukemia
 Malignancy of unknown cause affecting the
blood-forming organs
 Acute Lymphocytic Leukemia
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most prevalent in children
unrestricted proliferation of immature WBCs
 Signs/symptoms
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fever
abdominal pain
Leukemia
Signs/symptoms
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bone pain
anorexia
lethargy, malaise
pallor
hepatoplenomegaly
lymphadenopathy
petechiae, ecchymosis
Leukemia
 4 major problems associated with diagnosis
and treatment of leukemia
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1. Anemia
2. Infection
3. Hemorrhage
4. Leukemic invasion
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CNS involvement
 increased ICP, meningeal irritation, n/v, lethargy, H/A,
seizures
Leukemia
Diagnosis
 Established by a stained
peripheral blood smear
and bone marrow aspirate
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cells in the marrow are
precursor cells to those in
the periphery
normal marrow elements
are replaced with
abnormal cells
Leukemia
Treatment
 Chemotherapy
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set protocols
common side effects
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anorexia, n/v
alopecia
infection
 bone marrow depression
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mucous membrane ulceration
Leukemia
Nursing Care
 High Risk for Infection
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reverse isolation
skin care
nutrition
sterile technique
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central line - port-a-cath
labs
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ANC (absolute neutrophil count)
 multiple #WBC by % of neutrophils
Leukemia
Nursing Care
 PC: Hemorrhage
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assess skin for bleeding
dip stick urine
guaiac stool
guaiac emesis
bleeding gums
v/s
monitor labs
Nursing Care
 Hematological Precautions
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no rectal temps
no rectal medications
no injections
no visits to playroom
labs
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platelet count
Nursing Care
 Assess for complications of anemia
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bleeding
CHF
hypotension
changes in behavior
Leukemia
Nursing Care
 Altered Nutrition
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small frequent meals
foods child likes and are
nutritious
attractively served
keep child company while
eating
clean environment
good oral hygiene
Leukemia
Nursing Care
 Anxiety: child and family
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therapeutic communication
good listener
encourage family to help
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allow them some control
use play therapy
anticipate grieving
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 preschool.
 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.
 What diagnostic tests would your expect to be
ordered?
 Admission vital signs and labs are as follows:
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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
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lymphocytes 1,200
basophiles 30
eosinophiles 120
 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.”
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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.
 Chemotherapy regimen is started
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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?