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Hematology and Oncology Unit 6
Terms in this set (263)
What are erythrocytes?
What are leukocytes?
What are the different types of WBCs?
granulocytes: neutraphils, eosinophils, & basophils
agranulocytes: lymphocytes & monocytes
What does a CBC differential include?
granulocytes & agranulocytes
What are granulocytes?
What are agranulocytes?
What do erythrocytes do?
RBC-transports hemoglobin which carries oxygen to tissues, carries CO2 to the lungs and helps maintain pH by serving as an acid-base buffer.
What is hemoglobin?
Hgb-contents in RBCs that bind and transport O2
What is hematocrit?
Hct-~3X the hgb; this is the percentage volume of circulating packed RBCs in the whole blood.
What is the function of leukocytes?
WBCs-leukocytes play role in immune process.
How are neutraphils and monocytes used in the immune system?
involved in the primary inflammatory process
-neutraphils increase in acute inflammation and monocytes increase in chronic inflammation
What are eosinophils used for in the immune system?
-function not completely known but increase parasitic infections and allergic/anaphylactic type reactions, also may help to dissolve clots.
What are basophils' function?
not fully known but become mast cells in tissue. Basophils also release histamine during the healing phase of inflammation and allow increased permeability to allow the WBCs to exit vessels at the point of injury.
What is the function of lymphocytes?
increase with viral infections; vital to cell-mediated immunity and humoral immunity
What are the 3 types of T-cells?
cytotoxic T-cells (killer T's)
__-cells produce antibodies such as IgA, IgM, IgG, and IgE.
T-cells are what type of cells?
around 9.5-15 (up to 24 in <2 wks)
around 29-50 (up to 59 in 2-8 wks, up to 64 in >2 wks)
What do lymphocytes do in a bacterial infection? -
they change and become killer T's and helper T's.
When do monocytes show up during an infection?
come 2-3 days after infection. -They come in when infection is deemed chronic or lasts long. They are the big phagotizer (they come clean up)
What part of the blood has iron in it?
With a viral infection, what WBC differential value would the nurse anticipate to be abnormally elevated first?
Most common form of anemia & mineral deficiency in US.
Iron Deficiency Anemia
(also the most preventable)
What constitutes Iron Deficiency Anemia?
Iron low primarily from
, poor absorption, or increased loss or increased demand.
When iron deficient, unable to synthesis Hgb.
What are diagnostic values for iron deficiency anemia?
RBC, Hct, Hgb, MCV, iron values.
One molecule of hemoglobin consists of protein (globin) combined with four molecules of a pigmented compound (heme) each heme molecule has 1 Fe atom. So it takes __ atoms of iron per hemoglobin molecule!
With Fe deficiency anemia, may see normal or low normal RBC count but have low __. The cells may be __.
Hgb and Hct
small or pale
For iron defiency anemia, Infants under 1 year of age, MCV is low: __ fl is diagnostic.
Older children __ is diagnostic.
70 + age
When should iron testing be done?
in the morning when SIC is highest (serum iron concentration)
TIBC total iron binding capacity is the amount of __ which is necessary for iron transport in the bloodstream. This increases/decreases in iron deficiency because ---
transferrin ( iron binding globulin)
the body is trying to absorb iron from exogenous sources.
For every hemoglobin we need to have __ atoms of iron
What is the word for small cells?
What is the word for pale cells?
If someone has iron deficiency anemia, RBCs will be low/high.
How long do RBCs live?
How long does fetal hemoglobin last?
Too much __can cause low serum iron concentration
What are signs and symptoms of iron deficiency anemia?
Milk Baby Syndrome-overweight, pale, wheezy.
Fatigue, poor muscle tone
What are signs of extreme iron deficiency anemia?
glossitis (sores on the tongue), angular stomatitis (cracks in the corners of the mouth), koilonychia (spoon-nails), impaired cognitive function-social and behavioral problems.
What are the major symptoms of Iron deficiency anemia and why do they occur?
produces tissue hypoxia that results in:
fatigue, pallor, muscle weakness.
What are CNS signs of hypoxia?
irritability, impaired thought processes, can lead to permanent mental/cognitive impairment
Why will IDA pts. display tachycardia?
Decrease circulating oxygen stimulated the body to compensate by pumping faster and harder so the heart rate increases and an innocent systolic murmur occurs in the pulmonic area
What is milk-baby syndrome?
usually seen in an infant over 6 months who consumes too much milk at the expense of all other nutrients. The infant has too many calories is malnourished—no balance to diet. Baby is obese, with porcelain pale complexion, and wheezy. Will be anemic & will wheeze.
Nursing interventions for IDA.
Dietary education (Infants under 1 need to take and iron supplement if breast-fed and stores are low. Give iron fortified formula if not breast fed. At 6 months, introduce iron fortified rice cereal, progress to other cereals with iron and iron rich diet. Iron rich food—spinach and green leafy vegetables, red meats, etc. Do not introduce cow's milk until 1 year of age and limit milk/formula to 1 L/day.)
Administer supplements of ferrous sulfate
Promote rest to maximize oxygen to tissues & conserve it
Treat symptoms: milk baby syndrome cut milk consumption down to 1L/day, Improve overall nutrition for all patients. Frequent oral care to heal mouth sores.
What are side effects of ferrous sulfate?
nausea, gastric irritation, diarrhea, or constipation,and anorexia.
What are nursing considerations when administering ferrous sulfate?
If iron supplement causes vomiting or diarrhea administer with food and increase the dose gradually. Give with vitamin C/ascorbic acid—sources orange juice, lemon or lime ade, strawberries, tomatoes/tomato paste. Avoid giving within an hour of tea—tannins in tea bind iron and prevent absorption.
Liquid supplements must be given to from dropper, syringe, straw and teeth need to be brushed post dose.
Absorbed better between meals but if nausea and gastric upset severe give with meal. Will cause stools to be greenish black and tarry.
If no Increase in Hgb or tarry stools in 1 month assess administration/compliance.
IV iron administration can cause anaphylaxis. --check vital signs before you hang, q 15 mins into infusion, then 30 mins, then q hour until completed.
IM must be given z-track to prevent tissue discoloration. (will stain the skin)
What is the number one source of iron?
red meat -especially organ meats
What are good food sources of iron?
green leafy vegetables, red meat (esp. organ meat), Beans, potato skins, sorghum syrup, dried fruits (raisins), citric acid (tomato soup, ketchup, lemonade, strawberries, another source or vitamin C and absorbic acid)
Only transfuse iron if blood levels are less than--
What is Sickle cell anemia?
-an autosomal recessive disorder where Hemoglobin A (Hgb A) is replaced by hemoglobin (Hgb S).
-a condition where the hemoglobin crystallizes and takes on a crescent, slenderical shape that produces occlusions in circulation and shortens the BC lifespan.
When are sickle cell pt.'s cells normal?
when they are adequately hydrated and oxygenated
After a cell sickles, can it go back?
yes; they may sickle and unsickle
this repeated episodes produces damage to the cell and it will no longer revert back
What happens when a large number of cells sickle in a child?
the child enterees a stage of crisis and the sickled cells occlude the vascular bed and impede circulation
__% of sickle cell pts will have the disease
__% will have the trait
__% will be normal
In one parent has a trait and one parent has sickle cell disease, what are the risks for the children?
50% carriers & 50% disease
Why do sickle cell pts have so much pain?
When the cells cause occlusions in the vessels it decreases oxygenation to the tissues and causes hypoxia which is very painful
What is an emergency in kids with sickle cell anemia?
What may trigger a sickling response?
With HgB S, the RBCs are not stable under periods of stress:
When the cells convert in great numbers, it produces obstruction in the circulatory bed and destroys the RBCs called a __.
Pathophysiological Effects of SCA:
Circulatory Obstruction: Vasoocclusion
Strokes (Reduced cognitice impairment is the silent stroke result and about 20% of kids have had a silent CVA found only with MRI)
MI (chest pain that doesn't change with movement), CHF (chronic anemia causes the heart to pump harder to circulare the reduced volume & this makes the heart enlarged and weak), cardiomegaly
Chest syndrome (looks like pneumonia but no viral or bacterial infection present; infarct in the lung tissue)
Hepatomegaly (liver failure is common due to hepatic blood flow impairment from anemia and obstruction)
Asplenia (spleen becomes fibrotic and enlarged and stops filtering)
Ischemia induced hematuria
Dactylitis (hand-foot syndrome; this infarcts the bones & causes hands and feet to get puffy and may develop venous ulcers)
Osteoporosis (from hyperplasia and congestion in the bone marrow)
priapism (painful, sustained penile erection not associated with sexual arousal), retinal detactments, leg ulcers, & pain
Will an anti-platelet drug help with SCA crisis?
no. platelets are not causing the clot
If a SCA pt has leg ulcers, what is it most likely caused from?
Anemia from increased RBC destruction will cause-
-Liver-gallstone formation because the liver has to clean the blood & the excessive # of destroyed RBCs needing to be removed and absorbed lead to this.
-Kidney-free iron from RBC destruction leads to tissue necrosis and scarring; inability to concentrate urine, & enuresis
-Delayed growth and sexual development because of poor tissue oxygenation
-Reduced cognitive function
What are the different types of crises in SCA pts?
Vasoocclusive Crisis—painful crisis, most common
What is the most common sickle cell crisis?
What is vasoocclusive crisis?
It is non life threatening but very severe pain occurs as a result of the ischemia produced by the occlusion /infarct in the vascular bed. It can last from minutes to hours. Causes pain.
What is Sequestration Crisis?
caused by a malfunction of the spleen and occasionally the liver. The organs begin to absorb large quantites of blood. Leading to a rapid decrease in the circulatory volume and shock. In the acute crisis, the child must have surgery to remove the spleen or they will die from cardiovascular collapse. Chronic is a slow absorption of more than the usual amount of debris from the blood leading to hypersplenia. -spleen is a filter & now it becomes a giant sponge. Surgical emergency bc all blood volume is getting sucked into the spleen.
What is Aplastic Crisis?
a viral infection triggers a response in the bone marrow where hematopoiesis stops. So the rapidly destroyed RBCs are complicated with a lack of production---severe anemia. If the patient has hyplastic anemia and not a full blown aplastic then it is known as Megablastic anemia---excessive need for Vitamin B12 or folic acid during period of erythropoiesis. Usually temporary, give steroids to stop autoimmune process
What is a Hyperhemolytic Crisis?
increased RBC destruction triggered by a viral illness, transfusion reaction, or glucose -6-phosphate dehydrogenase deficiency. -usually after transfusion and something about it makes them lyse their RBCs. Can be triggered by viral illness.
How do we diagnose sickle cell?
CBC may reveal sickled cells
Sickledex- sickle turbidity test—can't distinguish between sickle cell anemia and the trait.
Hemaglobin electrophoresis—fingerprints the hemoglobin protein to determine the exact type of hemoglobin and the amount. Most diagnostic test.
What is the best test to determine sickle cell?
Does sickle cell only occur in African Americans?
What is nursing management that is essential for SCA?
-Minimize tissue hypoxia
-Promote rest to reduce energy expenditure
-Administer oxygen only if unable to maintain SaO2 at 90% or higher.
-Avoid low oxygen environments-high altitudes.
-Fluid requirements~ 1600ml/m2/day
Pain Control/Management (Morphine is the best med)
-Care must be taken during surgery to prevent tissue deoxygenation (transfusion prior to OR)
-Emesis is common in these children, do not limit fluids to prevent
Medications: Folic Acid, hydroxyurea, Desferoxamine (desferal)
Encourage genetic counseling and screening
What will you give for SCA for pain management?
demerol is contraindicated because they cause seizures
Does O2 reverse sickling?
how do we minimize crises in SCA pts?
take extra precautions to prevent and treat infections early. Infection big factor in hypoxia, dehydration, fever and metabolic acidosis. Handwashing used in hospital and at home, avoid know sources of infection—stay away from crowds when illnesses known in community. Teach patient and parents to seek medical care at first signs of infection. Teach family signs of crises and to seek medical attention promptly. WATCH FOR FEVER!
what is Desferal used for?
given SQ by pump overnight to prevent free iron released with RBC destruction from building up in tissues; binds the free iron so it doesn't do damage in tissues
How is hydroxyurea used?
—reduces risk of crisis and transfusions (makes RBCs stronger).
How is Folic acid used?
stimulates the production of red blood cells.
What nursing intervention is a priority in a child experiencing vasooclusive crisis?
Monitor oxygen saturation
Reposition every 2 hours
What is βeta Thalassemia?
Autosomal- recessive disorder;
the Beta chain of the hemoglobin molecule is defective and it results in very unstable RBCs. The RBcs are very rapidly destroyed (hemolysis occurs) because of the unstable hemoglobin molecule and release free iron into the circulation along with producing a severe anemia. The body is not able to make cells as fast as they are destroyed. They are doing well if the can keep cells for 30 days.
(Abnormal ß-chains produce a HgB molecule that is very unstable and RBCs are easily destroyed.)
The RBC hemolysis results in a build up of hemosiderin- iron- containing pigment from Hgb breakdown. This causes decreased Hgb synthesis and lysis of transfused RBCs.
What is Hemosiderosis?
increased iron storage in tissues
What is hemochromatosis?
cellular damage that results from increased iron storage in tissues
βeta Thalassemia Clinical Manifestations
Early anemia with pallor, poor feeding, enlarged spleen and liver, unexplained fever.
Progressing to signs of chronic hypoxia, headaches, precordial and bone pain, exercise intolerance, listlessness, anorexia
Physical feature changes: small stature, delayed sexual maturation, bronze, freckled complexion
Bone changes if not treated: enlarged head, frontal and parietal bossing, enlarged maxilla, flat or depressed nasal bridge, protrusion of the upper lip and central incisors, osteoporosis.
What may cause pain and organomegaly in Beta Thalassemia?
The cell destruction causes free iron to be released into the circulation and the liver and spleen work overtime to absorb the waste
What may cause fever in beta thalassemia?
failure of the spleen to clean up effectively
As anemia worsens in Beta Thalassemia, __ also worsens
Why may a Beta Thalassemia patient have bone pain and deformity
. The body tries diligently to replace the hemolysis occuring with new cells but erythropoiesis is not able to match the rate of cell breakdown. This produces bone pain and deformity of the flat bones responsible for hematopoiesis.
Basically the bones are trying very hard to make more cells.
As the iron deposits with Beta Thalassemia, this further produces signs—
bronze skin, freckling, bone hypertrophy and organ failure.
One of the leading causes of death with Beta Thalassemia is
Muscle gets really large and causes them to go into cardiac failure
Nursing Interventions for Beta Thalassemia: keep Hgb at __ or more with transfusions
Nursing Interventions for Beta Thalassemia:
Spleen enlargement safety
Cardiomegaly- leading cause of death
Help family cope with disease and be compliant
What is Desferal therapy used for?
Cell lysis leads to hemosderosis (iron overload) so desferal therapy is used as a chelating agent to bind the iron for excretion in the urine.
What are some nursing considerations for deferoxamine/desferal therapy?
Desferal- at night they put it in a butterfly in stomach and it binds the iron
**Expect red or amber color. Shouldn't have an odor, have a blue or green tint. Any signs of UTI we have to alter desferal therapy until it's gone. Must move the site if there is irritation. Can cause diarrhea and GI upset- blood in stool needs to be reported. Can cause hearing problems, visual disturbances (color disturbances as well). -Has helped with facial enlargement.
Must administer vitamin C with it to increase iron excretion
Given usually SQ via portable pump overnight 8-10 hour infusion. 5-7 days per week. During a transfusion may get it IV over 4 hours. It makes the excess free iron water soluble and excretes it in the urine. Urine turns red-orange. Make sure Urine output is good, and any UTIs need to be reported and therapy may be changed during the infection. May have diarrhea and GI upset—can cause bloody stools—needs to be reported. It can cuses decreased hearing, blurred vision, ,color vision disturbances. Anaphylacttic reactions.
What happens if Beta Thalassimia causes spleen enlargement?
have to have splenectomy. What to do for them? Prophylactic antibiotics should be given to protect from bacteria.
What are the benefits of a splenectomy in a Beta Thalassimia pt?
Splenectomy is performed and child 's need for tranfusions drop because the spleen's role in accelerating RBC destruction has ended.
Prognosis for Beta Thalassimia pt?
Most children survive until adulthood when treated with transfusions, chelating therapy and splenectomy. Leading cause of death is heart disease, postplenectomy sepsis, and multiorgan failure due to hemochromatosis.
What home care instructions should the nurse provide regarding deferoxamine (Desferal) Therapy?
-Monitor the infusion site and move if redness or swelling.
-Disregard any changes in vision or hearing.
-Expect the urine to have a strong odor and green color.
-Report any constipation.
Monitor the infusion site and move if redness or swelling.
Blood Transfusions: What are the steps?
Explain procedure to child & family
Assess spiritual or cultural concerns
Obtain history regarding previous transfusions (if they had a reaction before, more likely again)
Functioning IV (try a 22 or larger, but not 18 like usual)
Identify blood product, following protocol
2 people need to ID it is the correct blood product
Normal saline only to prime or flush tubing
Use an infusion pump / filter
Whole blood or components of blood may be administered
Obtain baseline VS prior to infusion; VS upon completion
Take vital signs frequently according to hospital policy
Premedicate with antihistamines and acetaminophen as needed
Monitor child for the initial 15-20 minutes of the infusion
Administer the first 50 ml of blood or 20% of volume slowly
Use blood within 30 minutes of arrival on unit
Infuse blood within a 4 hour time period (only good for this long)(If they need more than can be transfused over 4 hours the blood bank should divide it into 2 separate quantities)
Monitor closely for signs of a reaction
Do not mix medications with blood
Goals of administration of a blood transfusion?
Administer a compatible blood product
Treat the underlying problem
Nursing diagnoses for a blood transfusion?
Risk for injury
Fluid volume excess ****Stress the normal amt. to be given 10 mg / kg and rate is 5 ml/kg/min
Anxiety / fear
Indications for a blood transfusion?
Sickle cell anemia
Diagnostic Test for blood transfusions
H & P
ABO and Rh type and cross match
CBC, hgb, hct
what is considered a febrile reaction to a blood transfusion?
A 2 degree temp change
BP changes by 5-15
If someone is having a reaction to a blood transfusion, what do you do?
stop infusion, give fluids, and then call MD
Prioritiy is to stop the transfusion
Maintain airway: oxygen if needed / suction / head of bed elevated
Keep IV patent: NS to prevent clotting...may need to administer fluids or meds
Assess: Quick body assessment (lung sounds, rash-location etc)
Notify: physician, blood bank,
Document: on blood slip as well as nursing notes: include event, assessment and actions taken
patient response...monitor frequently
Most likely will need to draw blood and collect urine according to hospital policy
May need medications for low blood pressure, anaphylaxis (epinephrine vs saline bolus)
Blood transfusion reactions-
Fever / chills
Low back pain
Tachycardia, hypotension, tachypnea, shock & death
Flushing / itching / rash -most common
Dyspnea, cough, chest tightness, cyanosis
Nausea, vomiting & abdominal pain
Jugular vein distension / peripheral edema
What are complications of blood transfusions?
Febrile reaction- a 2 degree increase in temp., fluctuation in B/P
Mild allergic reaction
The nurse is administering a unit of packed RBCs to a 4 year old girl with β Thalassemia. The child's temperature at the start was 98.1ºF and 15 minutes into the transfusion it is 100.8ºF. What is most appropriate response by the nurse?
Administer the Acetaminophen prn.
Monitor the vital signs again in 15 minutes.
Stop the transfusion.
Give a dose of diphenhydramine (Benadryl).
stop the transfusion
What is Aplastic Anemia?
Suppression of all formed blood elements—
pancytopenia (anemia, leukopenia, thrombocytopenia).
Congenital aplastic anemia-
autosomal recessive trait
s/s patchy brown skin coloration (café au lait spots) -looks like coffee and cream spots, musculoskeletal and genitourinary anomalies (hypospadias, epispadias, cryptorchidism (undescended testicle), kidney and bladder malformations) sometimes born without an ulna, just a radius.
Acquired aplastic anemia
autoimmune process, infection, exposure to chemicals (dyes, petroleum products, benzene, paint remover, shellac and lacquers) , radiation, and drugs (anticonvulsants, antineoplastics antibiotics: chloramphenicol, cimetadine, sulfonamides.)
What is the leading cause of acquired aplastic anemia?
How is Acquired Aplastic Anemia diagnosed?
CBC, BMA with yellow, fatty bone marrow.
How is Acquired Aplastic Anemia treated?
Immunosuppression Therapy or BMT.
Immunosuppressive therapy is first line of treatment for acquired aplastic anemia if the child does not have a sibling match bone marrow donor. With immunosuppressive therapy the child is given antilymphocyte globulin (ALG) or antithymocyte globulin (ATG) with human recombinant granulocyte or granulocyte macrophage colony stimulating factor (to stimulate the bone marrow to produce WBC), methypredisolone (to control serum sickness associated with the ATG). If the ATG fails, Cyclophosphamide and GM-CSF is used. Androgens may be used to stimulate erythropoeisis if the aplastic anemia is unresponsive to the other therapies. Bone marrow transplant is best if done early prior to multiple transfusions which increase the leukocyte and HLA antigens when a suitable donor is available. Multiple transfusions prior to the BMT increase the rejection rate and lower survival rate.
Acquired Aplastic Anemia nursing interventions
Administer the G-CSF or GM-CSF with EMLA cream to reduce pain.
Reaction to treatment may produce N&V, alopecia, mucosal ulceration, oral ecchymotic areas can also occur so-
Meticulous oral care to prevent infection, skin breakdown, and bleeding.
Diet: liquid, bland or soft.
Prepare for ATG therapy and anaphylactic response to the ATG.
ATG is given IV usually through a central venous catheter. Meticulous CVL care very susceptable to infection, watch for extravasation at site. Anaphylactic response: have epinephrine, oxygen, readily available....any difficulty breathing, rash, or fever must be assessed for during infusion. Serum sickness can occur 7-14 days after tx which is similar to the anaphylactic response: fever, rash, difficulty breathing. Steroids help prevent this.
Care similar to leukemia.
Prognosis for Acquired Aplastic Anemia
With successful treatment 90% survival.
What do you think will happen to a male child who gets androgens?
Early puberty...closing of epiphyseal plates and short stature.
What is Hemophilia?
Bleeding disorder caused by a deficiency in one of the factors needed for coagulation.
What are the 2 most common types of Hemophilia?
Classic/ Hemophilia A/ Factor VIII defiency
Christmas disease/ Hemophilia B/ Factor IX def
How is hemophilia transmitted?
x-linked recessive transmission
(mother be a carrier and father have the disease)
Hemophilia usually effects males/females
it's really rare for a female to have it- mother would be a carrier and the father would have to have the disease
Hemophilia may be mild, moderate or severe in effects. What is mild hemophilia?
bleeding with severe trauma or surgery
Hemophilia may be mild, moderate or severe in effects. What is moderate hemophilia?
bleeding with trauma & injuries (good size fall)
Hemophilia may be mild, moderate or severe in effects. What is severe hemophilia?
spontaneous bleeding (no trauma)
Clinical Manifestations of hemophilia
Bleeding: patients can have spontaneous bleeding in head, gut, and joints. Observe for changes in neurological status. Occult or gross blood in stools, hematuria, epitaxis---treat nosebleed—direct pressure, ice, head straight, may pack with epinephrine containing nasal spray to vasoconstrict, etc.
Hemarthrosis-commonly in knees, elbows and ankles
Some also develop contractures because they don't do ROM exercises.
What is the first sign of a joint bleed in a hemophilia patient? What's the 2nd?
What do we do for this?
bruising and swelling
FRICE (factor, rest, ice, compression, elevation) & make sure child has ACTIVE ROM exercises after bleeding has stopped
What is hemarthrosis?
chronic condition...Joint is arthritic because of bleeds
Treatment for hemophilia?
Treatment-prevent, recognize, and control bleeding
(Do the RICE first, then give the factor as soon as stabilized. If they can stop the bleeding, they don't have to go to the hospital.)
Factor 8 or 9
epsiolon aminocaproic acid
Nursing interventions for hemophilia patients?
Care for and following Hemarthrosis
Educate parents on safe environment for infant and toddler to allow for normal development
Teach parents bleeding control and factor replacement
Avoid IM injections
Patients living before 1985-HIV risk
Active ROM exercises
Psychosocial adjustment and selection of appropriate activities-electric razor not blade, acetaminophen not ASA or NSAIDS, safe sex, swimming vs football
can only use electric razors
do not take rectal temps
What is DDAVP used for?
& what should you monitor when giving it?
Increases factor 8 in Hemophilia patients
helps control urine output; regulates hemophilia pts and makes factor 8 development stability
Monitor these pts for edema, alterations in urine output, and alterations in BP (can cause hypertension)
Factor is for __. How do you administer it?
hemophilia A. (gently roll to mix, don't shake) Give IV push
Corticosteroids are used in hemophilia for--
decreases inflammation, reduces inflammatory process in their joints
Corticosteroids for inflammation in acute hemarthrosis and synovitis, hematuria
What is Epsilon aminocaproic acid used for what in hemophilia?
helps prevent clot destruction
f they're going to have a surgical procedure or tooth extraction. Helps stabilize clots.
What do hemophilia patients have to do when they start losing their teeth?
they have to take factor 8 and apsilon aminocaproic acid.
The nurse is caring for a child who has been admitted with hemarthrosis. What nursing intervention is contraindicated?
Apply ice to affected limb.
Elevate the affected limb.
Encourage active range of motion.
Administer an IM dose of Morphine for pain.
Administer an IM dose of Morphine for pain.
What labs will be abnormal with hemarthrosis?
PT & PTT
Von Willebrand Disease (vWD)
Inherited bleeding disorder associated with a deficiency or alteration in a protein called von Willebrand factor which helps platelets adhere to the damaged epithelium and helps transport factor 8. S/S prolonged bleeding time, bleeding from mucus membranes: nosebleeds, gingival bleeding, easy bruising, excessive menstrual flow (menorrhagia). Affects both males and females.
Care Like Hemophilia-DDAVP and Humate-P
Mild, Moderate or Severe disorder can occur.
Bleed through tear ducts
Usually have gingival bleeding
Care of epitaxis:
Sit upright and lean forward. Don't lean back. Apply pressure to the nose with thumb and foreginger for 10 min. Ice on the bridge of nose. Pack with cotton ball or rolled gauze. Apply ice, Keep child quiet. May saturate the cotton ball or rolled gauze with Afrin or other epinephrine containing nasal spray.
Nursing interventions for Von Willebrand Disease (vWD)
While bleeding, we do nothing but hold pressure. After, put KY jelly on gauze and twirl in inside the nose so the scab doesn't form (so they won't pick it out).
Menstrual flow care wear plastic lined underpants and doubled sanitary pads (can be evident in hemophilia carriers as well)
Use soft bristle tooth brush and don't brush hard
Use a Water Pic instead of floss
They have normal platelet count so we don't want them on aspirin or any NSAIDS (no ibuprophen, Mobic, Celebrex)
What is Humate-P for Von Willebrand Disease (vWD)
(new treatment)- helps make factor 8 and con Willebrand factor increase.
What is the Most Common Cancer in Children?
What is leukemia?
WBC count is high due to immature cells; have high blast count in bone marrow. Mature WBCs are low in the CBC.
Bone marrow proliferations of WBC blast cells but circulating WBC is low at time of diagnosis—leukopenia. Not a solid tumor. Here the malignant cells proliferate in the bone marrow competing for nutrients with the noraml tissues. Thus, pancytopenia occurs—low RBC-anemia, low plts=thrombocytopenia, low WBC= leukopenia.
The cancer cells proliferate into the tissues and and organs. Especially lymphatic and central nervous system—brain, CSF and liver/spleen.
Riskfactors-genetic, viral infection, twin or multiple birth, Down's syndrome, preexisting immune disorders.
Over abundance of cancer cells in the bone marrow. Will absorb all the nutrients & proliferate. Always eventually effect WBCs. With these out of whack, other blood cells don't form. So they will be anemic, thrombocytopenic, etc.
Where is the cancer in leukemia?
neutrophils and lymphocytes
What will you see with a leukemia's CBC?
white count is elevated enormously
it's only elevated because it is abnormal blasts (malignant cells) in circulations. Not mature healthy cells.
Presenting S/S of leukemia
Presenting s/s depend on where the abnormal cells are & what's happening in the bone marrow:
URI/Cold that never goes away.
Fatigue, pale, irritable, anorexic
Bruising, petechiae, bleeding
Vague abdominal pain
Bone marrow has gone into overdrive to try to compensate loss
They have a lot of risks for metastasis because it travels
**Can set up in the spinal cord or testes (these are supposed to be "safe harbors" so sometimes chemo doesn't always get there)
S/S due to pancytopenia:
Low WBC—URI, Fever!
RBC's-Fatique, pallor, irritability—anemia
Low platelets---bruising, petechiae, bleeding
Bone pain a result of bM proliferation, vague abd pain spleen and hepatic invasion.
If the leukemia is making low white cells, what are its effects?
Usually it's that they can't shake a cold.
If the leukemia is making low red cells, what are its effects?
If the leukemia is making low platelets, what are its effects?
Types of Leukemia
Acute lymphocytic leukemia (ALL)-most common and best prognosis
Acute Nonlymphocytic Leukemia (ANLL) or Acute myelocytic leukemia (AML)
Prognosis for overall leukemias
ALL-best to have 85% survival and 95% remission rates
most common and best prognosis
if chemo puts into remission and comes back, they'll go to chemo plan B protocol because it is the most effective.
AML 60-70% survival poorer prognosis but still not bad
AML- If chemo puts them into remission and the cancer comes back, they get put on bone marrow transplant list
History, physical manifestations, CBC with differential
Bone Marrow Aspirate/Biopsy (BMA)
Lumbar puncture- aspirate spinal fluid and see if there is leukemic fluid in the spinal fluid.
Will see abnormally low almost everything
Numerous blast cells, immature, unspecified
Bone marrow looks just like red blood
BMA- draw out some bone marrow out of the illeac crest (from the back of the hip) and put it on slides.
Give it just like a blood transfusion
Stages of Treatment for leukemia?
Induction- put them into remission through initial chemo (<5% of leukemic cells)-they make them get an infusion for a week or maybe 24 hours
Intensification or Consolidation- After we start killing the cancer cells, the cells are weak and sick so now we give a drug that finishes them off. (treatment that is given a short time after induction to drive in the knock-out blow!)
CNS Prophylactic Therapy or Sanctuary Therapy- If they actually had cells in CNS, give treatment in the spinal cord (in the LP site) ---after this, we hope to be in remission.prevent or treat mets to CNS.
Maintenance- Come in once a month and get another dose of maintaince therapy depending on protocol (may last 1-2 years if stay in remission) Also get a bone marrow aspirate and LP to recheck.
Maintenance is period chemo to keep child in remission.
Reinduction- If they relapse and we start over with a new protocol and repeat induction.
What is Allopurinal?
Blocks uric acid formation, protects kidneys from free protein building up as uric acid from chemo
Allopurinol treat effects of tumor lysis syndrome. -controls uric acid build up (give this because develop uric acid crystals in urinary tract and kidneys) (they can go into kidney failiure bc whole kidney can turn into a kidney stone) -give lots of hydration to keep kidneys flushed. Alkolize the urine to keep acid from building: bicard drips as hydration fluids & Diamox.
Colony stimulating factors-
stimulate bone marrow to produce red and white cells
Ondansetron (zofran)- give it 30 mins. before chemo; reduces nausea- let them know it will help
THC (active ingredient in marijuana) given in a pill form -medical marijuana, Reglan & Vistaril combination, Fenagrin & thorazine ---these 2 can make BP drop (check bp before giving it ---pay attention to how you infuse. Fenagin burns so dilute it down. Always put it in at least 10 ml of fluid.
corticosteroids (PO,IT), vincristine (IV), L-asparaginase (IM), possibly doxorubicin (IV), methotrexate (IT), cytosine arabinoside (IT).
If someone has ALL, most mild form, they get corticosteroids into the spinal column -corticosteroids in high doses helps suppress leukemic cells.
Vincristine- neuropathic agent that damages the nervous system (causes neuropathy) -comes from periwinkles
Asparaginase- only drug that can be given IM, causes such severe anaphylaxis that 2 nurses have to be present and call doc before giving. Hold pressure on site after administration for 5 whole minutes while other nurse is checking BP every 5 mins
Doxorubicin (daumomycin, Adriamycin- cousin drugs) -it is red & is cardiotoxic. Must get an EKG and echocardiogram to make sure the heart muscle is strong enough. This is a vesicant (if ANY infiltration will cause 3rd degree burns in the tissues.) so toxic to the skin. If you are giving this, given IV push or 1 hour IV infusion every 5 mins aspirate for a blood return, if push- push a little, aspirate, push a little, aspirate...
Adriamycin has a maximum lifetime amount. (best breast cancer drug, but if they develop it later in life after having ALL as a child, they may can not have it.) Tell girls to wear light-day pads because it makes the urine red and will stain underwear
Methotrexate- IT= interthecally, in the spine
Cytosine arabinoside- remember that it causes severe bone marrow depression in 7-14 days (kills off all bone marrow and that's how it kills the cancer) -get ready for them to be anemic, thrombocytopenic, etc. Will start loosing their hair within 4 days. Also causes oral stomatitis. (can give magic mouthwash)
Cushing syndrome signs-
moon face, hump on back of neck, hershitism (hair on back or neck)
Side effects of corticosteriods?
Moodiness, ranvenous hungry, hyper, itchy, CAN ALTER blood glucose and blood pressure! Check these 2 before administration.
-these taste terrible, always have a strong chaser & don't dilute it too much, put some flavor in it. If they're old enough, peppermint is the best, if not, give them orange juice or grape.
How do we recognize neuropathy caused by VINCRISTINE?
-foot drop & constipation are the 2 most common (sliding their foot as they walk and when they lay down the foot goes limp.
What is the danger of doxorubin?
is cardiotoxic. Must get an EKG and echocardiogram to make sure the heart muscle is strong enough. This is a vesicant (if ANY infiltration will cause 3rd degree burns in the tissues.) so toxic to the skin. If you are giving this, given IV push or 1 hour IV infusion every 5 mins aspirate for a blood return, if push- push a little, aspirate, push a little, aspirate...
What is the best breast cancer drug?
What is dangerous about Cytosine arabinoside?
remember that it causes severe bone marrow depression in 7-14 days (kills off all bone marrow and that's how it kills the cancer) -get ready for them to be anemic, thrombocytopenic, etc. Will start loosing their hair within 4 days. Also causes oral stomatitis. (can give magic mouthwash)
cytosine arabinoside (IV, IT), doxorubicin or daunomycin (IV), methotrexate (IT).
Prolonged treatment of cytosine arabinoside & given doxorubicin to knock it out
What is Mtx-
antimetabolite, blocks RNA synthesis of nucleus—with high dose tratment can kill patient if rescue not give—leucovorrin
L'asparaginase nursing interventions—
IM only—can cause severe anaphylaxis,
When giving someone Desperol (for sickle cell to bind the iron) they also have to take
vitamin C (vitamin C store to help excrete iron just like to help absorb it)
Bone Marrow Transplant (BMT) -
if chemo fails, it is one of the leading treatments; take from the donor, put them in protective isolation in a sterile room. You have to watch them but be in full garb. Have to watch them for a pulmonary embolism because of the risk of fatty embolisms from the transplant.
child is radiated or given chemo to kill off their BM then donor marrow given IV infusion; stem cell transplant same way. Migrate to bone marrow and begin to produce cells.
Radiation in leukemia-
given ONLY IF they have CNS metastasis
The nurse is caring for a child with suspected leukemia. What CBC results would the nursing history reveal to Confirm this possible diagnosis?
Elevated Platelet Count.
What is Hodgkin Disease?
-A Lymphatic System Cancer
Lymphatic malignancy-occurs in lymph nodes, spleen, liver, bone marrow, lungs, mediastinum.
Most common in adolescents
Most common in adolescents
It's not uncommon to see a big mass that displaces the heart; will have arrhythmias & see and abnormal EKG
If bothering lungs, will have coughing, difficulty breathing, orthopnea, difficulty swallowing, etc.
How is Hodgkin Disease diagnosed?
Biopsy of tissues-lymph nodes and spleen --Sternberg-Reed Cells are found
Diagnosed after finding a sentinel node (enlarged lymphnode)
May have some upper respiratory symptoms
Night sweats, etc.
Confirmation is Sternberg-reed cells found
How to stage Hodgkin Disease?
Stage 1—really localized & if devide trunk in 4 quadrants it's only in one quadrant always above diaphragm (diaphragm being the central line)
Stage 2- only above the diaphragm
Stage 3- in 3 quarters of the body and has crossed the diaphragm
Stage 4—on all 4 quadrants
Hodgkin Disease chemo treatment
Historically: MOPP it up! (mustargen, oncovin (vincristine), prednisone, procarbazine. Now, using BEACOPP-Bleomycin, etoposide, adriamycin (doxorubicin), cyclophosphamide (cytoxan), Oncovin, Prednisone, Procarbazine; or ABVD adriamycin, Bleomycin, vincristine, dacarbazine
Great prognosis, follow-up important secondary malignacy rate high.
Assessment of Hodgkin Disease
Lymph node enlargement- is nontender, firm, moveable or mobile nodes in supraclavicular or cervical area. Typically L clavicle is sentineal node
Persistent nonproductive cough—mediastinal mass
Hodgkin Disease Treatment
Radiation- 1st round of treatment
BEACOPP-Bleomycin, etoposide, adriamycin (doxorubicin), cyclophosphamide (cytoxan), Oncovin, Prednisone, Procarbazine; or ABVD adriamycin, Bleomycin, vincristine, dacarbazine ==this is toxic to the lungs and causes them to get fibrotic etopooside- VP-16; anaphylactic producing; Check VS every 15 mins- always give epi if problem starts and have ambu bag ready
MOPP it up! (mustargen, oncovin (vincristine), prednisone, procarbazine.
Care of people getting radiation
causes disquamous changes (burns, but don't refer to it as burns) How do we protect the skin? -tell pts to bathe that place with just water or if ok'd by doc, can use emollient (moisturizing) soap like cedaphil, Dove (really oily soaps)
what is dangerous about Cytoxin-
give such high doses, given IV, can cause hemorrhagic cystitis (if the drug sits in bladder for too long, it causes bladder lining to sluff and will cause a massive hemorrhage. If they have ANY blood in the urine we will not give this. Make child pee every hour. Give this drug & then give 2X normal hydration fluid for massive flushing of urinary tract. It will be bright red blood. Monitor all urine.
what is dangerous about Procarbazine-
causes bone marrow suppression,
When someone with Hodgkin disease passes away, what is it commonly from?
heart and lung problems
What is the most common solid tumors in children?
astrocytoma, medulloblastoma, glioma, and ependymoma.
lower 1/3 of brain-cerebellum and brainstem 60% of tumors
in cerebrum-anterior 2/3 of brain only 40% of tumors
Assessment of Brain Tumor
Early a.m. HA
Vomiting progressing to projectile (unrelated to feeding)-compression of brainstem, the vomiting center in the medulla. Relieved by changing position.
Neuromuscular signs: clumsiness, loss of balance, weakness, loss of fine motor control because cerebellum controls gait
Behavioral changes: irritability, fatigue, lethargy, FTT, loss of appetite, staring, automatic movements (tics)
Cranial nerve: head tilt, nystagmus, diplopia, strabismus, graying out of vision
VS changes: B/P, HR & RR, unstable Temp regulation
S/S related to location of the tumor. These are common general s/s
Nursing Interventions for brain tumors?
☺Educate patient and family.
☺ Monitor VS q 15 mins, then 30, then hourly
☺ Neurological status- LOC, reflexes, hand grasps, cranial nerves—gag reflex especially, blink reflex, Pupil reaction to light, sleep pattern, responsiveness, once regain conciousness should maintain or increase not regress. A decrease in LOC after regaining conciousness indicates increased ICP.
☺ Maintain fluid balance-careful not to overhydrate increase ICP, hypotonic fluids increase ICP. DON'T WANT HYPOTONIC
☺ Pain control and comfort-may give morphine in small amounts to take the edge off
☺ Positioning-off op site
▪Infratentorial Tumors-usually flat, sidelying, keep head and neck midline because if cramp your neck and cut off carotid artery it cuts of O2 and blood flow and the body will try to compensate and send more blood there and that increases ICP; will have brain shifting if we lay them on the operative side; harder for gag reflex to come back so they are NPO longer
▪ Supratentorial Tumors-HOB
elevated ~ 30°
Monitor drainage and reinforce dressing. Colorless drainage indicates a Csf leak—nose, ear or wound---test for glucose.
We will be asking them the same questions over and over to make sure everything is working correctly.
Treatment OF brain tumors
Surgery has come a long way—guided by computers and lasers make it more precise. Important to support family during neurosurgery. The surgery itself comes with risks and may produce side effects. Give hope but be realistic...surgery may not return pre disease child to family. Benefits may not erradicate problems and may leave child with problem thay did not have prior to event.
Radiation—reduce tumor size to make more operable or following surgery to eliminate the remaining mass. SE of radiation—changes in the skin—do not call it burns—implies incorrect treatment. Radiation induced somnolence, endocrine dysfunction---diabetes insipidus, Sudden inappropriate ADH. Sterographical radiation- laser driven that goes directly to the site & is very pin-point and precise.
Chemo supplement ot surgery or/and radiation- not as affective as surgery and radiation. Helps to reduce tumor size but doesn't help control growth
Corticosteriods- helps decrease ICP and tumor size
Try radiation first, then use surgery.
We now have laser guided surgeries -let parents know that the pt. may not make them normal again. They may not regain the function they lost because of the tumor.
What is Osteogenic Sarcoma (osteosarcoma)
Bone tumor usually of long bones-femur #1, humerus, tibia, pelvis, jaw, phalanges
Common 10-25 years of age
Treatment of Osteogenic Sarcoma (osteosarcoma)
surgery-amputation or limb salvage, chemotherapy protocol- high dose methotrexate with leucovorin rescue, doxorubicin, bleomycin, actinomycin D, cyclophosphamide, ifosfamide, and cisplatin.
(anti-metabolite that blocks RNA synthesis, nucleus can not be formed, new cells can't be formed, the body will die; we have to start rescue with leucovorin very soon because they patient will die) with leucovorin rescue IV push (make sure everyone knows how important it is to get this medication on time; give at least 3 doses IV in hospital and send them home with PO doses. Stress to parents how important it is for them to have it on time), doxorubicin, bleomycin, actinomycin D, cyclophosphamide, ifosfamide (causes hemorrhagic cystitis but it has an antidote: mesna), and cisplatin (heavy metal; very expensive because it is made from platinum- causes severe n/v, causes low magnesium levels, will be put on mag supplements).
What is a common complication of Osteogenic Sarcoma (osteosarcoma)
Pulmonary metastasis common
If a child comes in with respiratory s/s we get an xray ordered
Grows through all of the tissues, infiltrates and becomes one with the bone
Requires surgical amputation
What is Wilm's Tumor?
Nephroblastoma-encapsulated intraabdominal tumor of the kidney and adrenal region-good prognosis. Genetic link. Congenital anomalies associated with aniridia, hemihypertrophy, hypospadias, cryptorchidism, ambiguous genitalia, microcephaly, ear malformations, mental retardation.
What assessment findings are significant in Wilm's tumor?
Abdominal mass, hypertension, hematuria
Detected by parents who find a mass in abdomen with bathing.
Treatment of Wilm's tumor?
surgery, radiation, chemotherapy protocol: actinomycin D, vincristine, doxorubicin, cyclophosphamide
Signs and symptoms of Wilm's tumor?
may have hypertension, hematuria, wt loss, fever, abdominal pain, anemia-pallor, fatigue, anorexia, lethargy, if large and pressing on diaphragm may see cough, dyspnea, SOB, and chest pain.
may all of a sudden have blood in urine
What safety measure is a priority nursing intervention for Wilm's tumor?
Preop-DO NOT PALPATE ABDOMEN (priority intervention) post a sign over head of bed to warn others. Educate child and family to protect tumor-no wrestling play or rough-housing that could rupture tumor.
Ewing's Sarcoma or Primitive Neuroectodermal Tumor (PNET)-
another bone cancer, usually no amputations. Thin & fine, floats on top of meris spaces; responds well to chemo & radiation- attacks more in flat bones (mandible & maxilla, hips)
arises in marrow spaces not osseous tissues so rarely requires amputation. Affects Femur, tibia, fibula, humerus, ulna, vertebra, scapula, ribs, pelvis, skull.
Treatment: radiation, chemotherapy: vincristine, actinomycin D, cyclophosphamide, ifosfamide, etoposide, doxorubicin
nervous system tumor- raccoon eyes or supraorbital ecchymosis, elevated vanillymandelic acid (VMA) and homovanillic acid (HVA) ONE OF THE MOST HIGHLY FAITAL CANCERS IN CHILDREN because metastasis has usually occurred before diagnosed
Silent Tumor, N-myc gene
Majority of tumors occur in sympathetic nerve chain in abdomen. Poor survival over 1-year of age
signs and symptoms of neuroblastoma?
depend on site. Metastatic sign is supraortital ecchymosis.
Treatment of neuroblastoma?
Surgery, Radiation, Chemotherapy: vincristine, doxorubicin, cyclophosphamide, cisplatin, teniposide, etoposide, ifosfamide, carboplatin.
Extremely Catecholemine excretion in urine see elevated VMA and HVA, dopamine, norepinephrine.
24 hour urine collection to test for the catecholemines; keep urine on ice
striated muscle cancer: occurs anywhere but commonly seen in the head and neck, or pelvis.
Striated skeletal muscle tumor that occurs in head and neck especially orbits, and cavities: pelvic, sinuses, middle ear, nose. S/S site dependent-pain, bleeding.
Treated with surgery (hysterectomy), radiation and chemotherapy: actinomycin D, ifosfamide, cisplatin, etoposide, carboplatin, cyclophosphamide, doxorubicin, topotecan, melphalan. Common cancer. Will see a white cluster.
Cat's eye reflex-Leukokoria
Retinal tumor; genetic factor
Leukokoria- cat's eye reflex (flashes back white)
Blindness in affected eye may occur. (most of the time)
microcirculation-helps preserve vision. Advanced tumor invoving optic nerve-surgical enucleation of eye. Chemotherapy stage V: vincristine, cyclophasphamide, doxorubicin, cisplatin, carboplatin, etoposide.
Care of prosthetic eye
Under anesthesia, they will lazer the tumor, cryotherapy and freeze tumor, and if there is metastisis down the nerve, they will do radiation
Treatment for Rhabdoblastoma-
surgery, radiation, chemotherapy.
Treatment for Retinoblastoma:
radiation (very localized) and radioactive implants, photocoagulation-laser cuts off tumor blood supply, cryotherapy-freeze tumor
clean prosthetic with just warm water
S/S of retinoblastoma
site dependent-pain, bleeding.
Treated with surgery, radiation and chemotherapy: actinomycin D, ifosfamide, cisplatin, etoposide, carboplatin, cyclophosphamide, doxorubicin, topotecan, melphalan.
common males ages 15-44;
-early detection important (TSE). -Treat with surgery (orchiectomy)
TSE started at SMR 3 or 13-14 years of age. 15-44 years of age, heavy painless testicular swelling
Treatment-orchiectomy and lymph nodes adjacent to tumor biopsied/removed.
Chemoptherapy is used with metastasis: cisplatin, etoposide, bleomycin, vinblastine and radiation.
Should do monthly testicular exams
Main thing is prevention
Good survival rate
Nursing Care of the Child With Cancer: Bone Marrow Depression-- anemia
(hgb <10 g/dl) Conserve energy
and oxygen. Procrit/ Epogen
conserve energy and oxygen. May have extreme fatigue because of the poor oxygenation from decreased RBCs. Innocent murmurs and tachycardia/tachypnea occur.
have to be symptomatic before they get a transfusion: innocent murmurs (it's affecting heart)
Conserve their energy and their O2
Nursing Care of the Child With Cancer: Bone Marrow Depression-- leukopenia/neutropenia
Infection from low WBCs or
neutrapenia (ANC<500/mm3 extreme neutrapenic precautions). Give G-CSFs -Key sign is FEVER
Neutrapenic precautions limit visitors and no ill caregivers. Avoid crowds, with counts at < 1000 /mm3, must stay at home strict handwashing, no raw fruits or veggies, no plants with counts < 500. Calculate absolute neutraphil count: WBC x % segs + % bands 1000 WBC x 8 (8%)segs + 4 (4%) bands =120 ANC. No reverse isolation on socially limiting does not help prevent infection.
S/s of local infection if you don't have white cells (neutropenic): no puss, warmth, or redness. It's just a raw place. IV sites that are just holes that haven't closed are infected. Normal inflammatory process will not happen. When white count is less that 1000, we put them on strict precautions.
Less than 500, they can't go outside of their room, no plants, no fruits or vegetables, limit visitors, no one coughing or sneezing can come in.
Will give granulocyte stimulating factors
Nursing Care of the Child With Cancer: Bone Marrow Depression-- thrombocytopenia
< 100,000/mm3 safety,
spontaneous bleeding at platelet
count <10,000/mm3 and may
stroke. No IM injections, no rectal
temps. Platelet transfusions with
increased risk of bleeding. No rough play or sports. At low levels <10,000/mm3 may have spontaneous hemorrhage—epitaxis, gingival hemorrhages, GI, Intracranial bleeds. No IM injections, rectal temps on people with bleeding potential.
protect from hemorrhageThey will have spontaneous bleeds
Less than 100,000- no outdoor play, stay indoors and play safe
Less than 10,000- risk for spontaneous bleeds and stroke
No brushing teeth
Have to give platelets IV push over 15-20 mins
Nursing Care of the Child With Cancer: Nausea and vomiting --
Vomiting- give antiemetics, control odors, preventing is better than trying to stop once started. Give med prior to antineoplastic therapy! Zofran
N&V treat prior to antineoplastic chemo agents administered and tell patient that you have given medicine to prevent N&V. Prevent odors of food in room or area, do not force child to eat during a treatment. Zofran (Ondansetron) great antiemetic!
Nursing Care of the Child With Cancer:Anorexia/altered nutrition--
May be a control issue, allow child to refuse meals during chemo and provide high protein & calorie foods, enteral feedings to supplement and maintain nutritional needs between therapy. Sometimes n/v causes anorexia, make sure they get nutrients. If they have a craving for something they can tolerate it well. Sometimes the anorexia is a control thing.
Try to get whatever the child wants to eat.
Nursing Care of the Child With Cancer: Mucosal ulceration/ Stomatitis-
gentle, frequent oral care, sitz baths for rectal area, use barrier ointment, no rectal temps.
clean teeth with toothette or cloth, use Normal saline, baking soda and water, Ulcerease, Nystatin, oragel, Peridex or magic mouthwash to help sooth or heal oral mucosa, avoid alcohol containing mouthwashes or lemon glycerine swabs--drying; sitz baths for rectal area, use barrier ointment, no rectal temps.
Nursing Care of the Child With Cancer: Diarrhea-
radiation or antineoplastic drug induced. Anal excoriation (no rectal temps), use barrier ointment, electrolyte imbalances.
Nursing Care of the Child With Cancer:Neurological problems:
footdrop and constipation from peripheral neuropathy induced by vincristine/vinblastine. Radiation induced somnolence.
Nursing Care of the Child With Cancer: Alopecia
surgical cap or cut hair prior to loss, get wig, fun hats or caps. Educate- will grow back and is usually darker and curlier.
Nursing Care of the Child With Cancer: Hemorrhagic cystitis
Cyclophosphamide or ifosfamide effect. Hydrate well and keep bladder emptied-urinate q 2 hours, MESNA helps protect bladder (ifos). Observe all urine for gross bleeding. During infusion void q hour, after q 2 hours.
Nursing Care of the Child With Cancer: Nephrotoxicity
Tumor/cell lysis syndrome-increased cell breakdown causes renal calculi/ crystallization-alkalinize urine (can cause kidney to shut down), hydrate-specific gravity very dilute<1.010, Allopurinol. Electrolyte imbalance-↑P+, K+, Ca+2
We want the pH to be 7 or greater.
Keep specific gravity very dilute
Monitor electrolyte imbalance
Nursing Care of the Child With Cancer: Tumor/cell lysis syndrome
-increased cell breakdown causes renal calculi/ crystallization-alkalinize urine, hydrate-specific gravity very dilute<1.010, Allopurinol. Electrolyte imbalance-↑P+ , High K+ (can give Kayexelate if getting potassium toxic), Ca+2 (troussou's sign and chevostec's sign)
Nursing Care of the Child With Cancer: Safe Handling of Antineoplastics
Safe Handling of Antineoplastics ---priming tubing; put on thick special gloves and let the end of the chemo drug go onto a sterile gauze- Can be absorbed into skin so if you're exposed, it's toxic; Dispose in chemo-biohazard places because we don't want it to get into the groundwater.
Children's Perceptions of Death
Adolescents-understanding of death is completely mature, abstract reasoning leads them into contemplating the afterlife. Know that is permanent but biggest threat is interferes with identity. Some magical thinking still present with thought this is a punishment for behavior. Difficult to accept their own death because struggling to form and identity and now confronted with nonexistence in life as they know it. Nurse needs to answer questions honestly, provide for privacy, respect feelings and emotions, treat them in a mature way.
Help them all through the grieving process. Dysfunctional grieving lasts for more than 1 year and is characterized by intrusive thoughts, pangs of severe emotion, distressing yearnings, feelings of being alone and empty, sleep disturbances, unable to function normally due to intensity of feelings of loss—needs counseling and support.
Want to leave a mark- help them to write their story, etc.
Leading cancer type in children.
This chemo drug is a heavy metal that causes nephrotoxicity, ototoxicity and
severe nausea and vomiting, and magnesium depletion.
Initial chemotherapy treatment, goal is remission.
This drug has a life time maximum dosage because it causes cardiomyopathy.
Frequent gently oral care helps prevent oral mucositis and this maouthwash may be included in this regimen.
A resulting complication of bone marrow suppression and neutrapenia.
Powerful antiemetic used to treat chemo induced nausea and vomiting. It's generic name is ondansetron.
This drug is a common intrathecal drug and is given as a high dose antimetobolite
IV--side effects are photosensitivity, N/V, diarrhea, mucositis, BMD, nephrotoxicity.
Bone marrow depression effect that causes petechiae, ecchymoses, and hemorrhage.
This is the brand name of a commonly used Granulocyte Colony Stimulating Factor.
Bone marrow depression effect that causes fatigue, lethargy, and pallor.
For a pancytopenic patient on chemo therapy, this route of temperature measurement
is contraindicated because it can worsen fissures and lead to bleeding or infection.
Abbreviated ARA-C is an agent used for leukemia treatment.
A nitrosureas abbreviation for carmustine a brain tumor chemo drug.
Leading site for osteogenc sarcoma.
This drug is used as a maintenance drug in leukemia--6 mercatopurine abbreviation.
Checking this tells you the alkalinity or acidity of the urine.
Antidote for Methotrexate.
Route for giving L'asparaginase.
Administration of chemo into the spinal canal.
Bone marrow depression occurs between ____ and 14 days following chemo.
Another sign of peripheral neuropathy that effects gait.
This medication helps prevent uric acid formation which is produced during tumor lysis syndrome and can lead to renal cystallization.
An encapsulated adrenal or kidney tumor. Has a genetic link
This drug can cause anaphylactic reactions, bradycardia, and hypotension,
and is abbreviated VP-16. Neurotoxicity can also occur.
A method of rectal cleansing that saves skin integrity _____ bath.
Bone marrow depression effect that wipes out the principle phagocytes.
This is a major complication of peripheral neuropathy.
Another term used for Ewing's sarcoma.
Term used for possible metastasis sites that can harbor or hide cancer cells--CNS and Testes.
Abbreviation for the old treatment of Hodgkin's. It really cleans up!
Ulcerations occur in this as a side effect of chemo.
A common side effect of chemo that leads to vomiting.
Cytoxan produces this serious side effect or complication -------------- cystitis.
Methotrexate side effect that requires sunscreen.
A major side effect of this drug is peripheral neuropathy.
I sound like a mineral but can cause hemorrhagic cystitis if you do not follow- up
with MESNA and keep the person receiving me hydrated well.
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