Presentation on theme: "Caring for Children with Alterations in Hematologic/Immunologic"— Presentation transcript:
1Caring for Children with Alterations in Hematologic/Immunologic Module 4Caring for Children with Alterations in Hematologic/ImmunologicChapter 26
2The Hemopoietic System Anemia'sWhat causes alterations in hemopoietic/immunological systems?acute blood losslong-term nutritional deficitacute/chronic systemic diseasegenetic disorders
3Assessment - Child’s History Dietarynutritional assessmentfood choices low iron contentFrequent infectionsExercise/play tolerancelevel of frustration02 capacityattention spanPainBleeding that is difficult to control
4Physical Exam Integumentary petechiae ecchymosis hematomas Color pallor look at conjunctiva, sclera, mucous membranesjaundice
7Screening and Diagnostic Tests CBCRBC’s - #of red blood cellshemoglobin/hematocritMCV - mean corpuscular volumereflects average size of each RBC - microcytic, normocytic or macrocyticMCH - mean corpuscular hemoglobinthe average hemoglobin content in each RBC
8Screening and Diagnostic Tests Platelet count - ability to clotReticulocyte count - # of young RBC’sWBCneed to look at differentialneutrophils - fight bacterial infectionbands - immature neutrophilslymphocytes - help develop antibodies and delay hypersensitivitymonocytes - clean upeosinophils - increased in allergic responsesbasophils - allergic responses
9Screening and Diagnostic Tests Other LabsSerum Ferritin - Iron storage proteinmeasured to assess the adequacy of iron reservesTIBC - total iron-binding capacityamount of available transferrin for binding more hemeFEP - free erythrocyte protoporphyriniron combines with proptoporphyrin to form heme
10Screening and Diagnostic Tests Peripheral blood smearabnormalities in shape and size of cellsOccult bloodlooking for bleedingHemoglobin electrophoresisdifferentiates the various types of hemoglobinBone marrow aspirationlook at development of blood cellssite posterior iliac crest
11Red Blood Cell Disorders Anemia Two Categories1. Those resulting from impairment in production of RBCs2. Those resulting from increase destruction or loss of RBCsClinical sign/symptomsrelated to the decrease in the oxygen-carrying capacity of the blood
12Anemia Signs/symptoms Initially are non-specificpallorirritabilityweaknessanorexiadecreased exercise tolerancelack of interest in surroundingMild anemiaasymptomatic or symptoms on exertion
13Anemia Signs/symptoms Severe Anemiaskin is waxy, sallow in appearancecardiac decompensation and CHFHgb 7-8g/100mlcardiac compensatory adjustments occurpallor of the skin and mucous membranes
14Anemia Signs/symptoms Sign of CHFtachycardiatachypneaSOBdyspneaedemahepatomegalyInfants may exhibit few s/s with a hgb 4-5g/100ml
15Anemia - Nursing Care Assessment v/s, I & 0 urine stool dip stick urinespecific gravitystooloccult bloodexamine skin for signs of petechiae
17Anemia - Nursing CareFood high in iron - especially with iron deficiency anemiagreen leafy vegetableseggs, organ meatscereals fortified with ironHydration - especially with sickle cell
18Anemia - Nursing Care major problem with blood dyscrasias handwashing Infectionsmajor problem with blood dyscrasiashandwashingprotective isolationv/s. - esp. the temprest periodsmeet needs promptlygood skin careAnxiety r/t hospitalizationTransfusions - blood and or platelets
19Iron Deficiency Anemia Most common between the ages of months and growth spurt in adolescencePossible causesinsufficient supply of ironimpaired absorption of ironAssessmentdetailed diary of dietary foods and amounts
20Iron Deficiency Anemia LabsCBC, Serum Ferritin, TIBC, FEP, Reticulocyte countTreatmentdietary education and changebe sensitive to cultural foods and beliefschanges take time and need supportdecrease milk intake
21Iron Deficiency Anemia Treatment Iron supplementtherapeutic levelsgive between meals with orange juicestains teeth - temporarystools changes - tarry greenpoisonous in improper dosage
22Red Blood Cell Disorders Sickle Cell Anemia Hereditary disorder characterized by abnormal type of hemoglobin - Hgb SSickling phenomenon - crisistakes place when oxygen tension in blood is loweredtriggersinfectiondehydrationexposure to coldstress - physical or emotional
24Sickle Cell Anemia Sickling Signs/symptoms RBCs sickle and clump together under low oxygen tensions causing a jamming effect in small vessels leading to tissue ischemiaSigns/symptomsInfancyfrequent infectionsfailure to thrive
25Sickle Cell Anemia Signs/symptoms irritabilitypallorhepatospenomegalyjaundicegrowth retardationOlder Childrenpainjoint, back and abdominal
26Sickle Cell Anemia Signs/symptoms nausea and vomitingfrequent infectionsesp. respiratory tractAll areas of the body are involvedsoft tissue swellingjoint swelling - painorgans suffer serious complications from tissue ischemia leading to infarctionliver failurekidney failure
27Sickle Cell Anemia Treatment rest to decrease oxygen consumptionpain managementhydrationoxygenationprotection from infectionprophylactic penicillinacute infectionIV antibiotics
28Sickle Cell AnemiaNisha 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 HR 110, RR 30, B/P 96/70, Sat 89%Wt. 50KgCBC wbc 12,000 hgb & hct 9 and 24, platelet 140,000What are your impressions of these values?
29Discuss 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?
30What do you think about the following orders? VS q4 hr, notify if T >100.4Reg dtB/R with BSCCBC with diff in am, UA and C/S, CXRD5% 1/2NS at 175ml/hrPCA - MS 1.5mg/hr with 1mg q 8min prnTyl 650mg po q4hr prn T >100.402 2L keep sat >94%
31What 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?
32Hemophilia Group of bleeding disorders Signs and Symptoms inherited deficiency of clotting factorSigns and Symptomsbleeding anywhere from or in bodyhemarthosishematomasexcessive bruising, minor injuryhematuria
33Hemophilia Treatment Prognosis replace clotting factor prevent bleedingRICEPrognosisno curecontrol symptoms - normal life spanBleed after IM
34Neoplastic Disorders Leukemia Malignancy of unknown cause affecting the blood-forming organsAcute Lymphocytic Leukemiamost prevalent in childrenunrestricted proliferation of immature WBCsSigns/symptomsfeverabdominal pain
35Leukemia Signs/symptoms bone painanorexialethargy, malaisepallorhepatoplenomegalylymphadenopathypetechiae, ecchymosis
36Leukemia4 major problems associated with diagnosis and treatment of leukemia1. Anemia2. Infection3. Hemorrhage4. Leukemic invasionCNS involvementincreased ICP, meningeal irritation, n/v, lethargy, H/A, seizures
37Leukemia DiagnosisEstablished by a stained peripheral blood smear and bone marrow aspiratecells in the marrow are precursor cells to those in the peripherynormal marrow elements are replaced with abnormal cells
38Leukemia Treatment Chemotherapy set protocols common side effects anorexia, n/valopeciainfectionbone marrow depressionmucous membrane ulceration
39Leukemia Nursing Care High Risk for Infection reverse isolation skin carenutritionsterile techniquecentral line - port-a-cathlabsANC (absolute neutrophil count)multiple #WBC by % of neutrophils
40Leukemia Nursing Care PC: Hemorrhage assess skin for bleeding dip stick urineguaiac stoolguaiac emesisbleeding gumsv/smonitor labs
41Nursing Care Hematological Precautions no rectal temps no rectal medicationsno injectionsno visits to playroomlabsplatelet count
42Nursing Care Assess for complications of anemia bleeding CHF hypotensionchanges in behavior
43Leukemia Nursing Care Altered Nutrition small frequent meals foods child likes and are nutritiousattractively servedkeep child company while eatingclean environmentgood oral hygiene
44Leukemia Nursing Care Anxiety: child and family therapeutic communicationgood listenerencourage family to helpallow them some controluse play therapyanticipate grieving
45Leukemia Case StudyAshlee 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.
46What 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 100/60CBCRBC 4.6WBC 4,000Hgb & hct 11 and 31Platelets 130,000Differential neutrophils 1, monocytes 290lymphocytes 1, eosinophiles 120basophiles 30
47How will you respond to her? 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.
48Chemotherapy regimen is started Zofran 2.5mg IV prior to chemo and then q4hrs for 24 hrs.Dexamethasone 16mg IV prior to chemoAtivan 1mg IV q4hrs for break thru nauseaDiscuss 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?