The Child With Conditions of Blood, Blood-Forming Organs, or Lymphatic System PDF 2023

**Reference:** Introduction to Maternity and Pediatric Nursing, 8^th^ ed., Leifer (2019), Chapter 27, pp. 638-656 **\ Hours of Instruction:** 4 **SECTION III. PRESENTATION** **B. ENABLING LEARNING OBJECTIVE** ----------------- -------------------------------------------------------------------...

**Reference:** Introduction to Maternity and Pediatric Nursing, 8^th^ ed., Leifer (2019), Chapter 27, pp. 638-656 **\ Hours of Instruction:** 4 **SECTION III. PRESENTATION** **B. ENABLING LEARNING OBJECTIVE** ----------------- ---------------------------------------------------------------------------------- **ACTION:** Provide nursing care to a child **CONDITIONS:** In a clinical environment, given a scenario **STANDARDS:** Provide nursing care to a child with a hematologic disorder without further harm ----------------- ---------------------------------------------------------------------------------- 1 Learning Step / Activity 1 Hematological System --- ------------------------------ ------------------------ Method of Instruction: Large group discussion Instructor to Student Ratio: 1:60 Time of Instruction: mins Media: Large group discussion 1\. The blood and blood-forming organs make up the hematological system. Blood is vital to all body functions. Blood dyscrasias or disorders occur when blood components fail to form correctly or when blood values exceed or fail to meet normal standards. 2\. Plasma and blood cells are formed at about the second week of gestation, primarily in the yolk sac. Later, blood forms in the spleen, liver, thymus, lymph system, and bone marrow. a\. In the fetus, blood is formed primarily in the liver until the last trimester of pregnancy. b\. During childhood, the red blood cells (RBCs) are formed in the marrow of the long bones (such as the tibia and femur) 3.Blood Components: two parts a\. Plasma 4\. Differences in infancy a\. The newborn has a high hemoglobin and red blood cell count at birth because of the high erythropoietin level, placental shift of blood to the vascular system at birth, and a low extracellular fluid volume. b\. A high white blood cell (WBC) level is evident at birth but decreases by 1 week to a stable level. c\. The vitamin K level is low in the newborn and is required for the development of several blood clotting factors, therefore vitamin K is administered immediately after birth. 5\. Lymphatic System 6\. Lymphatic system differences between children and adults a\. The increased size of tonsils and adenoids is normal in preschool and school-aged children and is one of the body's defense systems. b\. The thymus gland is important in the development of the immune response in newborns. c\. Preterm and term infants are at greater risk for viral and bacterial infections because of immature T-cell activity. **Check on Learning** **Summary:** **In this section, we** 2 Learning Step / Activity 2 Anemias --- ------------------------------ ------------------------ Method of Instruction: Large group discussion Instructor to Student Ratio: 1:60 Time of Instruction: mins Media: Large group discussion 1\. Anemia a\. Can result from many underlying causes. b\. A reduction in the amount of circulating hemoglobin reduces the oxygen-carrying ability of the blood. 2\. Iron Deficiency anemia a\. Pathophysiology 1\) Most common nutritional deficiency of children in the US 2\) The incidence is highest during infancy and adolescence due to the rapid growth periods. 3\) Caused by 3\. Sickle Cell Anemia a\. Pathophysiology 1\) Sickle cell disease is an inherited defect in the formation of hemoglobin. 2\) Occurs mainly in 1 out of 365 African American births. 3\) Carriers of the gene can have a Mediterranean descent 4\) Sickling (clumping) caused by decreased blood oxygen levels may be triggered by: rest, protection from infection, pain control, blood transfusion, and emotional support 4\) Teach parent the signs and symptoms of dehydration, hypoxia and infection to prevent occurrence of a crises. 5\) Cold or hot compresses should not be used to relieve pain, because cold promotes sickling and ischemia and ischemic tissues have reduced sensation there heat compresses can cause burns. 4\. Thalassemias **Check on Learning** **Summary:** **In this section, we** 3 Learning Step / Activity 3 Bleeding Disorders --- ------------------------------ ------------------------ Method of Instruction: Large group discussion Instructor to Student Ratio: 1:60 Time of Instruction: mins Media: Large group discussion 1\. Hemophilia 2\. Idiopathic Thrombocytopenic Purpura (ITP) a\. Pathophysiology 1\) Acquired platelet disorder that occurs in childhood 2\) Cause is unknown 3\) Thought to be autoimmune system reaction to a virus 4\) Platelets become coated with antiplatelet antibody, are perceived as foreign material, and are eventually destroyed by the spleen b\. Clinical manifestations 1\) Easy bruising and slowed blood clotting 2\) Petechiae: pinpoint hemorrhagic spots beneath the skin 3\) Pupura: hemorrhage into the skin 4\) Bleeding from mucous membranes; nosebleeds 5\) Platelet count less than 20,000 6\) Anemia if there has been bleeding c\. Treatment 1\) Identify spontaneous intracranial bleeding a\) Neurologic assessment are a priority of care 2\) Bruises of ITP must be distinguished from those of abuse 3\) Avoid meds that affect platelets a\) aspirin b\) phenylbutazone (Butazolidin) c\) phenacetin 4\) Activity is limited during the acute stage 5\) Focus on signs of bleeding a\) Gastrointestinal bleeding b\) Hemarthrosis c\) intracranial hemorrhage 6\) Use soft bristle tooth brush to minimize trauma 7\) Medications a\) Prednisone is first line treatment b\) IV gamma globulin (IVIG) may be used as a second line of therapy to elevate platelet count c\) Anti-D antibody infusion 8\) Keep up with vaccines especially those to prevent viral diseases 3\. Henoch-schönlein purpura a\. Pathophysiology 1\) Autoimmune illness that involves inflammation of the blood vessels 2\) Risk factors can be respiratory illness, NSAIDS or food allergies 3\) There is no thrombocytopenia in this condition b\. Manifestations 1\) Multiorgan involvement 2\) Petechiae 3\) Palpable purpura 4\) Ecchymosis 5\) Abdominal pain 6\) Gastrointestinal bleeding 7\) Hematuria c\. Treatment a\) General supportive care b\) Adequate hydration c\) Nutrition d\) Pain control e\) Steroids may be prescribed if kidney pathology is present **Check on Learning** **Summary:** **In this section, we** 4 Learning Step / Activity 4 Disorders of White Blood Cells --- ------------------------------ -------------------------------- Method of Instruction: Large group discussion Instructor to Student Ratio: 1:30 Time of Instruction: mins Media: Large group discussion 1\. Leukemia a\. Pathophysiology 1\) Group of malignant diseases of the bone marrow and lymphatic system. a\) Results in an uncontrolled growth of immature WBCs b\) WBC count is very high, but the cells are immature and don't work like mature WBC resulting in increased susceptibility to infection. c\) WBCs take over the centers that are designed to form RBCs, and anemia results. d\) WBCs infiltrate and take over the marrow centers that form platelets, the reduced platelet counts cause bleeding tendencies. e\) The invasion of the bone marrow causes weakening of the bone, and pathological fractures can occur. 2\) There are many types and classifications, each with its own therapy and prognosis. a\) The classification is important to the design of the individual treatment and prognosis 3\) This is the most common form of childhood cancer b\. Manifestations 1\) Low-grade fever 2\) Pallor 3\) Bleeding tendencies 4\) Leg and joint pain 5\) Listlessness 6\) Abdominal pain, 7\) Enlarged lymph nodes 8\) Skin has a lemon-yellow appearance 9\) Petechiae and purpura 10\) Anorexia, vomiting, weight loss, dyspnea 11\) Hematuria, anemia and thrombocytopenia 12\) Ulcerations from bacteria that enters the mouth c\. Diagnosis 1\) History 2\) Symptoms 3\) Bloodwork a\) Presence of leukemic blast cells in the blood b\) Bone marrow biopsy i\. Aspirated from the sternum or, more often in children, from the iliac crest. ii\. A special needle is used to obtain the sample, and the marrow is studied in the laboratory c\) X-ray films of the long bones show changes d\) Spinal tap determines central nervous system involvement. e\) Kidney and liver function studies are also performed because normal functioning of these organs is absolutely necessary for chemotherapy to be safely used in treating the disease d\. Treatment and Nursing Care 1\) Care involves multidisciplinary team a\) Pediatrician b\) Pathologist c\) Oncologist d\) Nurse e\) Radiotherapist f\) Nutritionist g\) Psychologist h\) School personnel 2\) Neutropenia may require isolation precautions 3\) Adequate hydration to protect the kidneys 4\) Delay routine immunizations 5\) Present attractive, favorite foods to help combat side effects of chemo a\) Offer foods high in protein and calories b\) TPN may be indicated to support nutrition 6\) I & O 7\) Observe for infection a\) Meticulous oral care and avoid commercial mouthwash b\) Watch areas where skin is punctured; pierced body parts c\) Turn frequently 8\) Thrombocytopenia bleeding is a common complication of leukemia a\) Observe for petechiae and eccymosis b\) Nosebleeds are common c\) Observe for evidence of bleeding on pillowcase 8\) Refer to available support groups a\) Encourage the child to verbalize feelings b\) Help with coping with the illness 9\) School tutoring and counseling should be continuous whether in the hospital or at home to promote growth and development e\. Radiation and chemotherapy target specific cells 1\) Components of chemo a\) An induction period b\) Central nervous system prophylaxis for high-risk patients c\) Maintenance d\) Reinduction therapy (if relapse occurs) e\) Extramedullary disease therapy 2\) Therapeutic effects are of short duration, so additional meds are used to maintain remission 3\) Medications a\) Prednisone i\. Side Effects \(1) masking symptoms of infections \(2) increasing fluid retention \(3) inducing personality changes \(4) Moon-shaped face appearance b\) Vincristine sulfate c\) daunorubicin or L-asparaginase d\) Chemo side effects i\. Nausea, diarrhea ii\. Fever iii\. Anuria iv\. Anemia v\. Bone marrow suppression vi\. Peripheral neuropathy causing constipation f\. Bone Marrow Transplant 1\) Autologous transplant a\) Uses the child's own bone marrow that has been purged of malignant cells 2\) Allogeneic transplant a\) taken from a donor who matches the child g\. Hemopoietic stem cell transplantation 1\) Used for children who do not respond to chemotherapy 2\) Very risky because the immune system must be destroyed before the transplant starts h\. Care of the child receiving a transfusion 1\) Identify the patient and donor blood types 2\) Double verify the information with another licensed professional 3\) Baseline vitals before the transfusion begins 3\) Observe for complications a\) Hemolytic reactions are rare b\) Treatment of transfusion reaction 2\. Hodgkin's Disease a\. Pathophysiology 1\) Malignancy of the lymph system that primarily involves the lymph nodes. 2\) Characterized by the presence of giant multinucleated cells called Reed-Sternberg cells and is diagnostic of the disease 3\) May metastasize to the spleen, liver, bone marrow, lungs or other parts of the body 4\) More common during early adolescence and early adulthood 5\) More common in boys than in girls **Check on Learning** **Question: A child with newly diagnosed leukemia does not have all immunizations up to date.** **Which is an essential step in response to this?** **a. Delay treatment until all immunizations have taken effect because a child with** **leukemia is immunocompromised** **b. Delay active immunization during chemotherapy** **c. Administer immunization on alternating days from chemotherapy** **d. Give immunizations according to the expected schedule; they do not interfere with** **treatment** **Answer: b** **Rationale: Active routine immunizations must be delayed (2), as opposed to delaying treatments** **(1) while the child is receiving immunosuppressive drugs, because the body will not be able to** **manufacture antigens as expected. This includes not administering immunizations either as** **scheduled (4) or on alternating days from chemotherapy (3). Parents should report any exposure** **to infections such as chickenpox so that immunoglobulin can be administered. Chickenpox can** **be life-threatening to a child who is immunosuppressed. Infection prevention may necessitate** **protective isolation precautions** **Summary:** **In this section, we** 5 Learning Step / Activity 5 Nursing care of the chronically ill child --- ------------------------------ ------------------------------------------- Method of Instruction: Large group discussion Instructor to Student Ratio: 1:60 Time of Instruction: mins Media: Large group discussion 1\. Nursing Care during chronic illness a\) Chronic illness during childhood often affects growth and development (Table 27.3). Chronic illness can impede growth and development. b\) Specific programs that foster feelings of security and independence within the limits of the situation are essential. c\) Behavior problems are lessened when patients can verbalize specific concerns with persons sensitive to their problems. 1\) The nurse anticipates a certain amount of reluctance to adhere to hospital regulations, which reflects the adolescent's need for self-determination. 2\) Recognizing this as an asset rather than a liability enables the nurse to respond creatively. d\) To be in school, and to be considered one of the group, is very important to children. 1\) If they feel rejected by and different from their peers, they may be prone to depression. 2\) Hospital school programs provide familiarity and enable patients to keep pace with their classmates. e\) The recreational therapist may also be helpful in combating boredom and providing outlets for tension. f\) Children who have a developmental disability that affects their intellect or ability to cope face some unique difficulties. 2\. Home Care a\) Children who have a developmental disability that affects their intellect or ability to cope face some unique difficulties. b\) Respite Care provides trained workers who come into the home for brief periods to relieve parents of the responsibility of caring for the child. 1\) Enables the parents to shop 2\) To take care of business 3\) Take a simple vacation 4\) Provides parents the opportunity for a normal spousal relationship c\) Home health care and other community agencies work together to provide holistic care. 1\) Focus on what the child can do 2\) Providing successful experiences are more effective than focusing on the disability 3\) Explain to the child what to expect 4\) Include the child in decisions and treatment 5\) Allow the child some control 6\) Promote normality of routines 3\. Nursing care of the dying child a\) The nurse must be aware of 1\) Understand the grieving process 2\) The personal and cultural views concerning that process 3\) The views of a parent losing a child 4\) The perceptions of the child facing death. b\) Nursing priorities include: 1\) Being a patient advocate and family advocate 2\) Providing support, and facilitating the grieving process c\) Hospice care may be available in the community and can play an important role in the care of the child and the family before and after death. d\) Self-exploration 1\) Own attitudes about life and death affect our nursing practice 2\) Must recognize that coping is an active and ongoing process 3\) Proper channeling of these emotions can be a valuable part of the empathetic response to others e\) Child's reaction to death 1\) Each child approaches death in an individual way, drawing on limited experience 2\) Nurses must be honest and inform patients about the upcoming procedures in terms the child will understand. 3\) Expressing feelings is encouraged and sufficient time should be given for a response 4\) Children should be allowed to have as much control as possible 5\) Children often communicate symbolically i\. Listen to talk with toys, and other children ii\. Crayons and paper provide self-expression 6\) Child's level of cognitive development, rather than chronological age, affects the response to death. i\. Younger than 5 years of age mainly involves separation from their parents and abandonment **Check on Learning** **Question:** The parents of a child dying from a terminal illness stay in the corner of the child's room, hugging each other and crying. What would be the best nursing intervention? **Summary:** - **Blood components** - **Anemia** - **Iron deficiency** - **Sickle cell** - **Beta-thalassemia** - **Hemophilia** - **Idiopathic thrombocytopenic purpura** - **Leukemia** - **Hodgkin's disease**