Module 4

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

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The Hemopoietic System

• Anemia's
• What causes alterations in hemopoietic/immunologic
  al systems?
• acute blood loss
• long-term nutritional deficit
• acute/chronic systemic disease
• genetic disorders

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Assessment - Childs 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
• petechiae
• ecchymosis
• hematomas
• Color
• pallor look at conjunctiva, sclera, mucous
  membranes
• jaundice

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Physical Exam

• Cardiovascular
• capillary refill
• tachycardia
• arrhythmias
• peripheral pulses
• Respiratory
• signs of CHF

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Physical Exam

• Musculoskeletal
• joint enlargement
• Lymphatic
• lymph node swelling
• G.I
• tenderness
• hepatosplenomegaly

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Screening and Diagnostic Tests

• CBC
• RBCs - 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

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Screening and Diagnostic Tests

• Platelet count - ability to clot
• Reticulocyte count - of young RBCs
• 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

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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

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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

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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

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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

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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

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AnemiaSigns/symptoms

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

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Anemia - Nursing Care

• Assessment
• v/s, I 0
• urine
• dip stick urine
• specific gravity
• stool
• occult blood
• examine skin for signs of petechiae

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Anemia - Nursing Care

• shock
• tachycardia
• pallor
• agitation
• thirst
• confusion
• Nutritional Needs
• calorie count
• daily wt.

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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

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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

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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

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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

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Iron Deficiency AnemiaTreatment

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

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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

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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

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Sickle Cell AnemiaSigns/symptoms

• irritability
• pallor
• hepatospenomegaly
• jaundice
• growth retardation
• Older Children
• pain
• joint, back and abdominal

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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

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Sickle Cell AnemiaTreatment

• rest to decrease oxygen consumption
• pain management
• hydration
• oxygenation
• protection from infection
• prophylactic penicillin
• acute infection
• IV antibiotics

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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?

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• 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?

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• What do you think about the following orders?
• VS q4 hr, notify if T gt100.4
• 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 gt100.4
• 02 2L keep sat gt94

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• 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?

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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

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Hemophilia

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

Bleed after IM
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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

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LeukemiaSigns/symptoms

• bone pain
• anorexia
• lethargy, malaise
• pallor
• hepatoplenomegaly
• lymphadenopathy
• petechiae, ecchymosis

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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

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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

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LeukemiaTreatment

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

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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

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LeukemiaNursing Care

• PC Hemorrhage
• assess skin for bleeding
• dip stick urine
• guaiac stool
• guaiac emesis
• bleeding gums
• v/s
• monitor labs

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Nursing Care

• Hematological Precautions
• no rectal temps
• no rectal medications
• no injections
• no visits to playroom
• labs
• platelet count

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Nursing Care

• Assess for complications of anemia
• bleeding
• CHF
• hypotension
• changes in behavior

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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

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LeukemiaNursing Care

• Anxiety child and family
• therapeutic communication
• good listener
• encourage family to help
• allow them some control
• use play therapy
• anticipate grieving

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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, familys 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.

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• 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

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• Tests confirm a diagnosis of acute lymphocytic
  leukemia, what is this?
• Ashlees 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 Ashlees
  prognosis.

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• 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 Ashlees level of growth and development
  and how her treatment may impact this.
• How can you work with Ashlees parents to help
  prevent complications associated with her growth
  and development?