Module 4
Caring for Children with Alterations in Hematologic/Immunologic
Chapter 26
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
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
Physical Exam
Integumentary petechiae ecchymosis hematomas Color
pallor look at conjunctiva, sclera, mucous membranes
jaundice
Physical Exam
Cardiovascular capillary refill tachycardia arrhythmias peripheral pulses
Respiratory signs of CHF
Physical Exam
Musculoskeletal joint enlargement
Lymphatic lymph node swelling
G.I tenderness hepatosplenomegaly
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
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
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
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
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
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
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
AnemiaSigns/symptoms Sign of CHF
tachycardia tachypnea SOB dyspnea edema hepatomegaly
Infants may exhibit few s/s with a hgb 4-5g/100ml
Anemia - Nursing Care
Assessment v/s, I & 0 urine
dip stick urine specific gravity
stool occult blood
examine skin for signs of petechiae
Anemia - Nursing Care
shock tachycardia pallor agitation thirst confusion
Nutritional Needs calorie count daily wt.
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
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
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
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
Iron Deficiency AnemiaTreatment
Iron supplement
therapeutic levels
give between meals with orange juice
stains teeth - temporary
stools changes - tarry green
poisonous in improper dosage
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
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
Sickle Cell AnemiaSigns/symptoms
irritability pallor hepatospenomegaly jaundice growth retardation
Older Children pain
joint, back and abdominal
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
Sickle Cell AnemiaTreatment
rest to decrease oxygen consumption pain management hydration oxygenation protection from infection
prophylactic penicillin acute infection
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.
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 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? 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. How will you approach her?
What are her teaching priorities for discharge?
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
Hemophilia
Treatment replace clotting factor prevent bleeding RICE
Prognosis no cure control symptoms - normal life span
Bleed after IM
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
LeukemiaSigns/symptoms
bone pain anorexia lethargy, malaise pallor hepatoplenomegaly lymphadenopathy petechiae, ecchymosis
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
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
LeukemiaTreatment
Chemotherapy set protocols common side effects
anorexia, n/v alopecia infection
bone marrow depression mucous membrane ulceration
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
LeukemiaNursing Care PC: Hemorrhage
assess skin for bleeding dip stick urine guaiac stool guaiac emesis bleeding gums v/s monitor labs
Nursing Care
Hematological Precautions no rectal temps no rectal medications no injections no visits to playroom labs
platelet count
Nursing Care
Assess for complications of anemia bleeding CHF hypotension changes in behavior
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
LeukemiaNursing Care Anxiety: child and family
therapeutic communication good listener encourage family to help
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 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.
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
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.
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?