By Jeanie Ward - PowerPoint PPT Presentation


PPT – By Jeanie Ward PowerPoint presentation | free to download - id: 72e937-NzM0O


The Adobe Flash plugin is needed to view this content

Get the plugin now

View by Category
About This Presentation

By Jeanie Ward


Childhood Cancers Iron Deficiency Anemia What is wrong ... Crisis Spleen Function Spleen in the Infant Teach Parents How to Measure Spleen Treatment for ... – PowerPoint PPT presentation

Number of Views:144
Avg rating:3.0/5.0
Slides: 116
Provided by: Jeani181
Learn more at:


Write a Comment
User Comments (0)
Transcript and Presenter's Notes

Title: By Jeanie Ward

Hematologic Disorders
  • By Jeanie Ward

Iron Deficiency Anemia
Iron Deficiency Anemia
  • What is wrong?
  • What causes Iron Deficiency Anemia in Children?

Iron Deficiency Anemia
  • Manifestations
  • Pallor Pale mucus membranes
  • Enlarged spleen and heart
  • Poor muscle tone with decreased activity
  • Fatigue
  • Diagnosis
  • low hemoglobin (lt11g/100mL)
  • Low hematocrit (lt33)
  • RBC are small and hypochromic
  • Serum iron levels are low (? 30µg/mL)

Iron Deficiency Anemia Treatment
  • Oral iron supplements
  • What additional supplement should be give
  • What is important to teach regarding diet? What
    foods high in iron?

Sickle Cell Disease
Sickle cell Disease
  • What is wrong?

What causes the cell to sickle?
  • Low Oxygen tension (less than 60-70)
  • Low blood pH (acidosis)
  • Increased blood viscosity (dehydration, fever,

Result of Sickling Process
  • The sickled RBCs do not move freely through the
  • Blockage in vessel / blood flow halts
  • Tissue distal to the blockage becomes
  • ischemic
  • Acute pain, cell destruction,
  • tissue death

General Manifestations
  • Chronic anemia (Hgb. 6-9 g/dl.), pallor,
    weakness. Unable to do physical activities
    because of lack of stamina
  • Fatigue, malaise
  • Anorexia
  • Jaundice
  • Possible delayed sexual maturation
  • Marked susceptibility to sepsis
  • Possible growth retardation with long bones
    disproportionately long.

Types of Sickle Cell Crisis
Vaso-Occlusive Crisis
  • Occurs from the pooling of many of the new
    sickled cells in vessels with resulting tissue
  • May last from one
  • day to several weeks

Manifestations of Vaso-Occlusive Crisis
  • Bone Pain
  • Most outstanding symptom
  • Mainly in the bones of the extremities and
    joints, but can occur anywhere
  • Abdominal and back pain is common
  • Related to necrosis of bone tissue
  • Parents may notice this with refusal to move an
    extremity, crying out with joint movement or
    joint touched.

Hand and foot Syndrome Dactylitis
  • Painful swelling of the hands and /or feet.
  • May be the first symptom of crisis
  • Warmth in affected areas.
  • Fever

Cerebrovascular accident
  • Vaso-occlusion in the brain
  • results in cerebral infarction
  • which causes variable degrees
  • of neurologic damage
  • Hemiplegia
  • Aphasia
  • Seizures
  • Vision changes
  • Headaches
  • Alterations in level of consciousness

Acute Chest Syndrome
  • Blockage of blood vessels
  • in the chest leads to
  • Pneumonia and
  • acute chest syndrome
  • Chest pains
  • Fever, cough
  • Dyspnea, retractions
  • Leading cause of death in SCD.

  • Persistent painful erection
  • of the penis occurring when
  • penile blood flow is obstructed.

  • Enlarged liver with jaundice and hepatic coma.
  • related to damage to the kidneys

Aplastic Crisis
Aplastic Crisis
  • Diminished RBC production resulting in severe
  • Manifested by
  • Malaise, lethargy
  • Headache
  • Pallor
  • fainting

Aplastic Crisis
  • Profound anemia- low RBC count is lifelong. The
    average RBC life is down to an average of 10-20
    days in SCA.
  • Jaundice, elevated bilirubin
  • Reticulocytosis
  • Bone marrow producing 3-4 times more RBCs than

Sequestration Crisis
Acute Sequestration Crisis
  • Sickled cells become trapped in the spleen
    obstructing blood flow with pooling and
    enlargement of the spleen.
  • Leads to shock and hypovolemia
  • Circulatory collapse and death can occur in less
    than 30 minutes

Spleen Function
  • Acts as a filter against foreign organisms that
    infect the bloodstream.
  • Filters out old RBCs from the bloodstream and
    recycles them
  • Minor Role
  • Manufacturers RBCs toward end of fetal life
  • and after birth, taken over by bone marrow.
  • Acts as a blood reservoir.

Spleen in the Infant
  • Soft, purplish-red organ that lies under the
    diaphragm on the left side of the abdominal
  • Filters old blood and clears bacteria

Teach Parents How to Measure Spleen
  • A tongue depressor can be used to measure and
    track spleen size
  • Place tip on left nipple and make mark where the
    spleen tip is felt

Treatment for Sequestration Crisis
  • Intravenous fluids
  • Blood transfusion
  • Spleen removal

Effects of Chronic Crisis States on the Childs
  • Spleen more susceptible to infection. Gradual
    fibrosis and scarring with reduction in spleen
    activity. Asplenia.
  • Liver enlarged, firm, tender
  • Brain single episode of sickling CVA,
  • Heart enlarges and murmurs develop
  • Lungs pulmonary edema and stasis
  • Kidneys hematuria, unable to concentrate urine
  • Bone Infarcts hands and feet swell.

Effects of Chronic Crisis States on the Childs
  • Eyes bleeds in retina.
  • Leg Ulcers
  • Are seen in 10-15 of older children
  • May start as simple insect bite or cut that does
    not heal
  • With poor circulation develops into leg ulcer
  • Treated with dressings, leg elevation and elastic

Diagnostic Tests
  • CBC low hgb and hct
  • Hemoglobin electrophoresis used to determine
    type of hemoglobin. When you pass an electric
    charge through a solution of hemoglobin, distinct
    hemoglobins move different distances, depending
    on their composition. This technique
    differentiates between normal hemoglobin (A),
    Sickle hemoglobin (S).

Goals in Care
  • The is NO CURE for the disease
  • Treat the Symptoms
  • Relieve the pain
  • Provide oxygenation
  • Adequate hydration

Pain Management
  • Give analgesics as ordered
  • Schedule nursing care to allow for optimal rest
  • Position joints with pillows
  • Application of warmth
  • Promote circulation through passive ROM

  • Assess Oxygen saturation- pulse oximetry. Should
    be 95 or gt.
  • Administer Oxygen for short period of time to
    keep saturation levels up.
  • Bedrest to minimize energy expenditure and oxygen
  • Administer blood transfusions

What are Complications associated with frequent
blood transfusions?
  • Allergic reaction
  • Circulatory overload
  • Iron Overload
  • Give Desferal, an iron-chelating agent, to
    decrease the iron levels

  • Prevent infection, dehydration
  • Avoid emotional stress, overfatigue
  • Avoid prolonged exposure to heat and cold
  • Avoid low oxygen environment

Hydration/ Electrolyte Replacement
  • Encourage fluid intake, at least the minimum
    amount of fluid required daily for that childs
    weight. (1-2x maintenance)
  • Record I O. Monitor electrolyte balance
  • Give parents written instructions on specific
    amount of daily intake needed.
  • Assess signs of dehydration (decreased urination,
  • Teach parents measures to prevent dehydration
    such as avoiding heat / stress.

Prevent Infection
  • With the spleen damaged, has greater chance of
    getting sepsis.
  • Avoid know sources of infection
  • Assess Vital Signs and report elevated
    temperatures. Treat with Ibuprofen, NOT ASA.
  • Place on prophylactic antibiotics such as
    Penicillin VK 250 mg twice a day, through age 5

Prevent Infection
  • Hepatitis B series
  • Recipient of blood and blood products.
  • Pneumococcal
  • Pneumovax for now at age 24 months and 5 years,
    with an improved vaccine coming on the market
    soon for administration to infants.
  • Meningococcal vaccine
  • H. influenzae vaccine

Child / Parent Teaching
  • Assess baseline knowledge and teach accordingly
  • Causes of disease and consequences, genetic
  • Situations that cause sickling
  • Signs of developing crisis, infection,
  • When to call the doctor
  • Keep in school, promote normal gd as much as
  • Allow for decreased endurance - let the child
    set his or her own pace during strenuous
    exercise, and to take rest breaks when fatigue
  • Explain some complications CVA, anemia,
    swollen spleen, liver problems
  • Support child and family

Critical Thinking
  • Which of the following nursing diagnoses should
    receive priority during a vaso-occlusive crisis
    in a 14 year old with sickle cell anemia?
  • A. Alteration in comfort
  • B. Ineffective individual coping
  • C. Decreased cardiac output
  • D. Ineffective airway clearance

Critical Thinking
  • Which of these instructions should the parents of
    a child who has recovered from a sickle cell
    crisis receive?
  • A Isolate child from known sources of infection
  • B Avoid contact with all children
  • C Restrict childs intake during the night
  • D Reinforce the basics of trait transmission

  • What goes wrong?
  • Who gets this?

Do Hemophiliacs bleed more Profusely than people
without Hemophilia?
Hemophiliacs bleed mainly from minor cuts
  • True or False

Related to the deficiency of AHF
Interviewing the Child with Hemophilia
Subjective Data
  • Recent traumas and measures used to stop bleeding
  • Length of time pressure was applied before
    bleeding subsided
  • Was swelling increased after surface bleeding
  • Did swelling and stiffness occur without apparent

  • Prolonged bleeding anywhere from
  • or in the body.
  • When is it most often diagnosed?

Classic Sign - Bleeding
  • Surface bruising - Bleeding from trauma into
    soft tissues and muscles (the ileopsoas muscle
    around the hip, calf, forearm, upper arm,
    achilles tendon, buttocks, retroperitoneal.
  • Hematuria
  • Hemarthrosis - bleeding into joints (knees,
    elbows, ankles, shoulders, hips, wrists in
    descending order of frequency)

  • CNS bleeding - Major cause of death
  • Signs and Symptoms of CNS bleeds
  • Persistent or increasing headache
  • Repeated vomiting
  • Sleepiness or a change in normal behavior
  • Sudden weakness or clumsiness of an arm or leg
  • Stiffness of the neck or complaints of pain with
    neck movement
  • Complaints of seeing double
  • The development of crossed eyes
  • Poor balance when walking, a lack of coordination
  • Convulsions or seizures

Assessment of Child
Bleeding in the mouth
Surface bruising
Diagnostic Tests
  • DNA testing for the trait
  • Blood Tests
  • Partial Thromboplastin Time (PTT) Prolonged
  • Bleeding time Prolonged gt 2 hrs.
  • Platelet count and Prothrombin time Normal
  • Low levels of Factor VIII

  • Prevent and control Bleeding
  • Prevent crippling effects / Decrease pain
  • Child/ Parent Teaching

Interventions to Prevent or Control Bleeding
  • What is the basic priority treatment to stop or
    prevent bleeding in people with hemophilia A?
  • Why this is the priority?

Additional Interventions to Prevent and Control
  • Administration of DDAVP (desmopressin acetate)
    nasal spray used to stimiulate release of factor
    VIII. Used with mild hemophilia
  • Apply local pressure for 10-15 minutes
  • Elevate joint above level of heart
  • Apply cold compresses to promote vasoconstriction
  • Prophylactic administration of factor VIII

Interventions to Prevent Crippling effects /
Decrease Pain
  • During bleeding episodeelevate joint and
  • ROM after acute episode
  • Exercise unaffected joints and muscles. Give
    analgesics before Physical therapy. Do NOT give
  • Watch diet/ weight excessive weight stresses
    the joints

What is the crippling Effect of Repeated bleeds
into a Joint?
  • Bleeding in joints, especially knees, ankles and
    elbows can lead to
  • loss of range of motion
  • muscle loss
  • destruction of the joints themselves

Child / Parent Teaching
  • Measures to prevent injury/ providing a safe
  • Early recognition of bleeding episodes
  • Keep current on immunizations
  • Hepatitis B because recipient of blood and
    blood products

Child / Parent Teaching
  • How to administer factor VIII.
  • Children often learn how to infuse themselves at
    the age of eight or ten. Then, the hemophiliac is
    able to treat himself at home, at school, at camp
    or on vacation.

Critical Thinking
  • A 12 year old hemophiliac child has been admitted
    to the hospital for hemarthrosis. Which of these
    expected outcomes should receive priority in the
    childs care?
  • A. Family will receive genetic counseling
  • B. Child will participate in appropriate
    activities for present condition
  • C. Child and family will seek support from
    National Hemophilia Foundation
  • D. Maximum function of the joint will be restored

  • Following administration of factor VIII to a nine
    year old child admitted to the hospital with
    hemarthrosis, the nurses next action would be
  • A. Elevate and immobilize the affected joint
  • B. Institute passive range of motion to the
  • affected joint during the acute phase
  • C. Apply warm compresses to the affected
  • joint
  • D. Apply pressure to the area as needed

Childhood Cancers
CancersAlmost all childhood cancers involve
blood or blood-forming tissues
Childhood Cancers
  • Brain tumors second leading cause of death from
    childhood cancer.
  • Most are cerebellar and brain stem tumors
  • Lymphomas
  • Non-Hodgkins lymphomasone-third present with a
    mass in the neck or mediastinal area. Also have
    dyspnea, wheezing, abdominal mass or pain and
  • Hodgkins disease arises in single lymph node
    with painless nodal enlargement, followed by
    extension to adjacent nodes and into spleen,
    liver, lungs, bone marrow.
  • Neuroblastoma malignant tumor arising from
    sympathetic NS ganglion cells outside the cranium
    and and can arise from anywhere along the
    sympathetic nervous system chain. Can also occur
    in retroperitoneal area, pelvis, neck.

  • Wilms Tumor solid tumor of kidney.
  • Rhabdomyosarcomamalignant tumor of the striated
    muscle cells.
  • occur in muscles around eye, head, neck,
    extremities, GU system.
  • Retinoblastoma intraocular malignancy of the
    retina of eye. Usually unilateral. If bilateral
    , hereditary. First sign is white pupil.
  • Others osteogenic sarcoma/ Ewings sarcoma
    tumor of bones of the trunk. Often seen in
    adolescence growth spurt. Found in distal femur,
    proximal tibia.

Warning Signs of Childhood Cancer
  • C continual unexplained weight loss
  • H headaches with vomiting (early morning)
  • I increased swelling of pain in joints
  • L lump or mass
  • D development of whitish appearance in pupil
  • R recurrent or persistent fevers, night sweats
  • E excessive bruising or bleeding
  • N noticeable paleness or tiredness

Diagnostic Tests
  • What is the major way cancer is diagnosed?
  • What are additional tests?
  • Blood Tests
  • CBC
  • Uric Acid
  • Bone Marrow Aspiration
  • MRI, CT, ultrasound

  • Radiation therapy
  • Chemotherapy
  • Surgery
  • Bone Marrow and Stem cell transplantation

Radiation Therapy
Changes the DNA component of
a cell nucleus The cell cannot
replicate which Inhibits further cell
division and growth
Effects of Radiation Therapy
  • Radiation sickness- anorexia, nausea, vomiting
  • Treated with antiemetics (Zofran or Anzimet).
    Cool cloth to forehead, provide distraction,
    accurate IO.
  • Fatigue
  • allow for naps an rest periods (coordinate care),
    encourage parent to cuddle in bed with child,
    pillow, blankets, favorite toys
  • Skin reactions erythema, tenderness

  • Bone marrow suppression anemia, neutropenia,
  • May be on reverse isolation
  • Mucositis- inflammation of mucus
  • membranes mainly the mouth
  • Offer soft foods, and cold foods.
  • Frequent mouth care. Lidocaine oral to swish in
    mouth (older child)
  • Long term depends on part of body receiving

  • There are several categories of antineoplastic
    drugs used in treating childhood cancers.
  • Scheduled at set times and days and by different
    predetermined routes.
  • May remain in hospital for few days at first,
    then later report on specific day for therapy.
  • Children and Parents must be taught about what to
    do and not to do during therapy.

Side effects and Toxic Reactions to
  • Bone Marrow Suppression neutropenia, anemia,
  • Place in reverse isolation, keep anyone exposed
    to a virus away from patient.
  • Monitor temperature
  • Should not receive live-virus vaccines
  • Bleeding Tendency (thrombocytopenia)
  • Apply pressure to puncture site
  • No contact sports
  • Check urine and stool for blood
  • Give stool softeners. WHY?
  • Soft objects in mouth

  • Malaise and fatigue
  • Encourage video games, movies, etc
  • Allow visits from friends
  • Nausea, vomiting, diarrhea, anorexia
  • Give anti-emetics
  • Small frequent meals
  • Monitor for dehydration
  • Altered mucous membranes
  • Stomatitis
  • Rectal ulcerations

Side effects of chemotherapy
  • Renal involvement
  • Uric acid levels rise as a result of breakdown of
    cells. The renal tubules causing renal failure.
  • If kidney affected/damaged- chemo drugs will not
    be excreted as usual and may limit drugs given.
  • Body Image changes
  • Alopecia
  • Pain

Review of Common Side Effects ofChemotherapy and
  • Radiation side effects
  • Skin reactions
  • Fatigue
  • Bone marrow suppression
  • Nausea
  • Vomiting
  • Anorexia
  • Mucositis
  • Chemotherapy
  • Bone marrow suppression
  • Alopecia
  • Malaise/fatigue
  • Nausea
  • Vomiting
  • Anorexia
  • Stomatitis

  • Curative
  • Remove the tumor and cancerous tissue
  • Palliative
  • Relieve complications due to the cancer

Bone Marrow and Stem Cell
  • The goal of therapy is to administer a lethal
    dose of chemotherapy and radiation therapy that
    will kill the cancer and then re-supply the body
    with bone marrow and stem cells to reconstitute
    immunologic function.
  • Healthy bone marrow or stem cells are infused
    into the bloodstream and migrate to the marrow
    space to replenish the patients immunologic
    function and help kill remaining cancer cells.

Types of Transplantations
  • Syngeneic
  • bone marrow comes from identical twin
  • Allogeneic
  • bone marrow comes from matched sibling (one in
    four chances) or someone who is histocompatible.
  • Autologous
  • own bone marrow. May be harvested at time of
    remission in preparation for relapse or when bone
    marrow is free of malignant cells. Also being
    used so toxic doses of chemotherapy and radiation
    can be administered and the bone marrow rescued.

  • First --All potential donors are typed for HLA
    (human leukocyte antigen) compatibility.
  • Collection of bone marrow is a surgical
  • The donor undergoes anesthesia for aspiration of
    the bone marrow
  • The bone marrow is then processed and frozen
  • When patient ready - it is infused into the

  • Where is the most common site for bone marrow
    aspiration in children?

Side effects of Transplantation
  • 1. Graft-Versus-Host Disease (GVHD)
    potentially lethal immunologic response of donor
    T cells against the tissue of the recipient.
  • Signs and symptoms rash, malaise, high fever,
    diarrhea, liver and spleen enlargement.
  • Because there is no cure, prevention is
    essential. Careful tissue typing, irradiation of
    blood products which helps to inactivate mature T
  • 2. Rejection of the transplant

Post Therapeutic Disabilities
  • CNS cognitive disorders, seizures, headaches,
    coordination problems
  • Bone asymmetric growth of bones, easy
    fractures, scoliosis, kyphosis
  • CV cardiomyopathy (pericardial thickening) ,
    pericardial damage
  • Respiratory pneumonitis, pulmonary fibrosis
  • GI enteritis, bleeding, hepatic fibrosis
  • Urinary hemorrhagic cystitis, reflux
  • Endocrine decrease in growth, thyroid and
    gonadal dysfunction
  • Reproductive decrease sperm
  • Dental - caries
  • Secondary malignancies 

Ask Yourself?
  • What is the most common form of childhood cancer?
  • a. leukemia
  • b. brain tumors
  • c. lymphoma
  • d.osteosarcoma

What is wrong?
How does that impact the body?
  • The WBC's are produced so rapidly that immature
    cells (blast cells) are released into the
  • These blast cells are nonfunctional, can't fight
    infection, and are formed continuously without
    respect to the body's needs
  • The blasts cells then invade other organs and
    interfere with metabolism / function. The
    production of red blood cells and platelets
    decreases leading to anemia and thrombocytopenia.

Signs Symptoms
  • Bone marrow Depression results in
  • Decrease in mature WBCs - fever
  • Decrease RBCs, Anemia- pallor, lethargy,
  • Decreased Platelets/ thrombocytopenia- ? bleeding
  • Increase cell metabolism which deprives cells of
  • Enlargement of organs infiltrated with blast
    cells results in
  • Bone pain
  • Spleenomegaly. Hepatomegaly, Nephromegaly
  • Lymphadenopathy
  • CNS infiltration increased ICP

Diagnostic Tests
  • History and Physical
  • Blood Work
  • Leukocytes are gt 10,000
  • Platelet count, Hgb and Hct low
  • Blast cells appear (where they normally dont)
  • Bone Marrow Aspiration
  • Used to identify the type of WBC involved,
    therefore, type of leukemia
  • X-rays of long bones
  • Show lesions caused by invasion of abnormal cells
  • Lumbar Puncture blast cells in the CSF

Chemotherapy is the most common treatment for
Leukemia. Why?
  • A combination of antineoplastic drugs are given
    for about a month
  • A different combination is given for about 2-3
  • Advantages of using a combination of drugs
  • Decrease resistance to one drug
  • Lessening of severe side effects of massive doses
    of one drug
  • Breakdown of the tumor cell cycle at multiple

Chemotherapy Phases
  • 1. Remission induction- most intense treatment.
    Large doses of antineoplastic drug administered
    in an effort to destroy as many proliferating
    cells as possible. Lasts 4-6 wks. About 95
  • 2. Consolidation- method of destroying leukemic
    cells in the CNS- for children who have CNS
    involvement or are high risk. Given Intrathecal.
  • 3. Remission maintenance- drugs given at
    specific intervals. If remain in remission for 3
    yrs, treatment is discontinued. Approx 80 of
    children who sustain remission for 2-3 yrs
    continue to remain in remission and appear to be

Administration of Chemotherapy
  • When is intrathecal administration of
    chemotherapeutic medications required?
  • Intrathecal chemotherapy is instilled in to the
    spinal canal for cancers that have metastasized
    to the brain

What is the rationale for the use of cranial
radiation in addition to chemotherapy?
Nursing Care
  • Prevent infection (neutropenia, anemia)
  • Pain Relief
  • Nausea and vomiting
  • Mouth discomfort-mucositis / stomatitis
  • Fatigue
  • Alopecia
  • Prevent blood loss-platelet low- nose bleed most
    common kind of bleed
  • Support child and family
  • Assist with referrals to social services, home
    health agency, chaplain

Nursing Care
  • Community Resource
  • Candlelighters Childhood Cancer Foundation
    (CCCF) is a national non-profit membership
    organization whose mission is to educate,
    support, serve, and advocate for families of
    children with cancer, survivors of childhood
    cancer, and the professionals who care for them.
  • http//
  • American Cancer Society
  • Make a wish Foundation
  • Leukemia Society
  • Church and Schools

Tumor Lysis Syndrome p. 1325
  • Caused by the breakdown (lysis) of malignant
    cells which release intracellular contents into
    the blood.
  • Intracellular electrolytes overload the kidneys
    and can lead to kidney failure.
  • Further severe electrolyte imbalances cause
    metabolic acidosis, hyperkalemia, increase uric
    acid levels, hypocalcemia and cardiac

Tumor Lysis Syndrome
  • Hydrate with IV fluids containing bicarbonate
    which alkalinizes the urine preventing formation
    of uric acid crystals which damage the kidney
  • Treatment
  • Treat with IV fluids, electrolyte replacement,

Wilms Tumor
  • An embryonic tumor of the kidney.

Etiology and Pathophysiology
  • Cause is unknown
  • Originates from immature
  • renoblast cells
  • Tumor is vascular

  • Palpable abdominal mass
  • Firm and smooth
  • The abdomen should not be palpated
    once the
  • diagnosis is made. Avoid palpating
    the tumor mass
  • during assessment because of the
    risk of rupturing the
  • protective capsule. Excessive
    manipulation can cause
  • seeding of the tumor and spread of
    cancerous cells
  • Abdominal distention
  • Fever
  • Fatigue
  • Late signs
  • Anemia
  • Hematuria, dysuria
  • Hypertension

Diagnostic Tests
  • Abdominal ultrasound
  • CT, MRI
  • Biopsy

  • Nephrectomy and removal of lymph nodes
  • Post-op chemotherapy and / or radiation therapy
  • CT every 6 months for 3 years
  • Chest x-ray every 3 months for 3 years

Nursing Care
  • Pre-op
  • Sign on bed Do Not Palpate Abdomen
  • Child / Parent teaching
  • Post-op
  • Monitor kidney function, Strict I O
  • Monitor vital signsB/P and temperature
  • Monitor GI function assess bowel sounds and
    stool production
  • NG tube to drainage. Measure abdominal girth.

Death and Children
  • Caring for a child who is dying can be one
    of the hardest tasks in nursing

Understanding of Death
  • Children under 3
  • Have no understanding of own impending death
  • May perceive family anxiety, sadness
  • Preschool to 5 years
  • More afraid of separation from parents than of
    thought of dying. Greatest fear is separation.
  • Envision death as temporary, and have little of
    adults fear of it
  • Think of it as a long sleep, not a final process.
    Nightmares increase.
  • May feel pain / illness is a punishment for
    misdeeds or thoughts
  • May ask questions about death
  • In long term illness may simulate adult
    response with depression, withdrawal,
    fearfulness, anxiety

  • School Age 5-9
  • Begin to understand that death is permanent
  • May think it is something that only happens to
  • Become aware of what is happening to them when
    their disorder has a fatal prognosis.
  • Concerns center around fear of pain, fear of
    being left alone and leaving parents and friends.
  • May associate death with sleep and may be afraid
    to go to sleep without someone near them.
  • May associate death with darknesswant light left
    on in room

Understanding Death
  • Adolescent, older school age
  • By age 10 have an adults concept of death,
    realizing that it is inevitable, universal, and
    irreversible. Have more understanding than adults
  • Understand that death is the cessation of life.
  • Emotional outbursts may reflect anger
  • View death as fearsome and fascinating (increase
    in adolescent suicide).
  • May feel immune to death and deny symptoms for
    longer than usual because they believe it is
    impossible that anything serious could happen to
  • Some adolescents consider themselves alienated
    from their peers and unable to communicate with
    their parents for emotional support feeling alone
    in their struggle.

Nursing Care Child
  • Elicit child's understanding of death before
  • Encourage children to express feelings in own way
    through play, drawings, or verbalization to
    promote free expression.
  • Provide a safe, acceptable outlet for expressions
    of feelings
  • Structure care of child to allow child choices
    and participation in process within constraints
    of physical condition
  • Help child maintain independence and control
    normal ADL as much as possible (set realistic
  • Realize that they will go through the stages of
    dying denial, bargaining, anger, depression,

Nursing Care Parents
  1. Spend time with family to listen, answer
    questions, and provide information. Discuss
    issues with parents before discussing with child.
  2. Provide opportunities for family to express their
    emotions and deal with their feelings. Parental
    reactions continuum of grief process and usually
    depend on previous experiences with loss,
  3. Reactions may depend on relationship with child
    and circumstances of illness or injury
  4. Reactions depend on degree of guilt felt by
    parents-help them sort out

  • Assist parents in expressing fears, concerns,
    grief to enable them to appropriately support
  • Assist parents to understand sibling' possible
    reactions to terminally ill child
  •    Guilt- believing they caused the problem or
  •   Jealousy- wanting equal attention from
  •    Anger- feelings of being left behind
  • Support, enhance parent-child communication,
    enhance parents' ability to support child
  • Refer to parent, family support groups- not
    alone, help focus, open communication, provide

Nursing Care Nurse
  • Nurse needs to care for self.
  • Care of the caregiver is imperative if the nurse
    is to provide physical and psychosocial care for
    families at such a difficult time.
  • Caring for dying children and their families can
    be stressful and emotionally demanding.