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Module 4

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Title: Module 4


1
  • Module 4
  • Caring for Children with Alterations in
    Hematologic/Immunologic
  • Chapter 26

2
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

3
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

4
Physical Exam
  • Integumentary
  • petechiae
  • ecchymosis
  • hematomas
  • Color
  • pallor look at conjunctiva, sclera, mucous
    membranes
  • jaundice

5
Physical Exam
  • Cardiovascular
  • capillary refill
  • tachycardia
  • arrhythmias
  • peripheral pulses
  • Respiratory
  • signs of CHF

6
Physical Exam
  • Musculoskeletal
  • joint enlargement
  • Lymphatic
  • lymph node swelling
  • G.I
  • tenderness
  • hepatosplenomegaly

7
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

8
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

9
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

10
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

11
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

12
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

13
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

14
AnemiaSigns/symptoms
  • Sign of CHF
  • tachycardia
  • tachypnea
  • SOB
  • dyspnea
  • edema
  • hepatomegaly
  • Infants may exhibit few s/s with a hgb
    4-5g/100ml

15
Anemia - Nursing Care
  • Assessment
  • v/s, I 0
  • urine
  • dip stick urine
  • specific gravity
  • stool
  • occult blood
  • examine skin for signs of petechiae

16
Anemia - Nursing Care
  • shock
  • tachycardia
  • pallor
  • agitation
  • thirst
  • confusion
  • Nutritional Needs
  • calorie count
  • daily wt.

17
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

18
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

19
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

20
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

21
Iron Deficiency AnemiaTreatment
  • Iron supplement
  • therapeutic levels
  • give between meals with orange juice
  • stains teeth - temporary
  • stools changes - tarry green
  • poisonous in improper dosage

22
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

23
(No Transcript)
24
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

25
Sickle Cell AnemiaSigns/symptoms
  • irritability
  • pallor
  • hepatospenomegaly
  • jaundice
  • growth retardation
  • Older Children
  • pain
  • joint, back and abdominal

26
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

27
Sickle Cell AnemiaTreatment
  • rest to decrease oxygen consumption
  • pain management
  • hydration
  • oxygenation
  • protection from infection
  • prophylactic penicillin
  • acute infection
  • IV antibiotics

28
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?

29
  • 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?

30
  • 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

31
  • 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?

32
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

33
Hemophilia
  • Treatment
  • replace clotting factor
  • prevent bleeding
  • RICE
  • Prognosis
  • no cure
  • control symptoms - normal life span

Bleed after IM
34
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

35
LeukemiaSigns/symptoms
  • bone pain
  • anorexia
  • lethargy, malaise
  • pallor
  • hepatoplenomegaly
  • lymphadenopathy
  • petechiae, ecchymosis

36
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

37
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

38
LeukemiaTreatment
  • Chemotherapy
  • set protocols
  • common side effects
  • anorexia, n/v
  • alopecia
  • infection
  • bone marrow depression
  • mucous membrane ulceration

39
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

40
LeukemiaNursing Care
  • PC Hemorrhage
  • assess skin for bleeding
  • dip stick urine
  • guaiac stool
  • guaiac emesis
  • bleeding gums
  • v/s
  • monitor labs

41
Nursing Care
  • Hematological Precautions
  • no rectal temps
  • no rectal medications
  • no injections
  • no visits to playroom
  • labs
  • platelet count

42
Nursing Care
  • Assess for complications of anemia
  • bleeding
  • CHF
  • hypotension
  • changes in behavior

43
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

44
LeukemiaNursing Care
  • Anxiety child and family
  • therapeutic communication
  • good listener
  • encourage family to help
  • allow them some control
  • use play therapy
  • anticipate grieving

45
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.

46
  • 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

47
  • 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.

48
  • 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?
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