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?