Week 14 Pediatrics

Ewing Sarcoma:

Following amputation, phantom limb pain is a temporary condition that some children may experience. This sensation of burning, aching, or cramping in the missing limb is most distressing to the child. The child needs to be reassured that the condition is normal and only temporary.

Brain tumors:

Headache and morning vomiting related to the child getting out of bed. Headaches worsen on arising but improve during the day.

What is the genetic transmission pattern of hemophilia?

It is an X-linked recessive chromosomal disorder transmitted by the mother and expressed in male children.

Tay-Sachs:

Jewish genetic disorder/disease is a rare inherited disorder that progressively destroys nerve cells (neurons) in the brain and spinal cord.

Wilms tumor:

Nephroblastoma, malignant renal tumor, in the flank area, confined to midline; a solid cancerous tumor of the kidney. DO NOT PALPATE ABDOMEN" - because of the risk of rupturing the encapsulated tumor and subsequent metastasis. - Excessive manipulation can cause seeding of the tumor and cause spread of the cancerous cells. - Fever, hematuria, and hypertension are also some clinical manifestations

What are the priorities for a client with a Wilms tumor?

Protect the child from injury to the encapsulated tumor. Prepare the family and child for surgery

Radiation treatments:

Sun protection is essential during. The child should not be exposed to sun during these treatments

Chemotherapy

Suppresses phagocytotic neutrophils and places the child at risk for infection. After chemo is completed-flush tubing with saline and heparin.

Preoperative Teaching Prior to Surgery:

Turn/Cough/Deep Breathe (TCDB) use pillow to splint; help prevent atelectasis & help lower risk of lung complications after surgery.

Atelectasis

is a condition that occurs when your entire lung or a part of your lung gets deflated. This results in the reduction or absence of proper gas exchange in the body.

Grief in Children: Preadolescent to Adolescent

- Adolescent may regress. - Adolescent sees death as permanent. - Adolescent experiences a strong emotional reaction.

Nursing interventions and medical treatments for a child with leukemia are based on what three physiologic problems?

- Anemia (decreased erythrocytes) - Infection (neutropenia) - Bleeding thrombocytopenia (decreased platelets)

Autosomal Recessive Diseases

- CF - PKU - Sickle Cell Anemia - Tay-Sachs - Albinism *25% chance if: AS (trait only) X AS (trait only) *50% chance if: AS (trait only) X SS (disease)

Blood transfusuion:

- Check calcium levels; monitor for neuromuscular *manifestations of hypocalcemia (e.g., tetany, muscle twitching/irritability, cramping, grimacing, seizure, altered deep tendon reflexes, and spasm). - Hypocalcemia (<7 mg/dL): inability to store and absorb calcium. Hypocalcemia: jitteriness, apnea, increased muscle tone, edema, abdominal distention, feeding intolerance, and Chvostek sign (twitching over tapped parotid gland) - Nursing Interventions: *Stop transfusion. *Change tubing, then continue saline IV. Treat for shock if present. *Draw blood samples for serologic testing. Monitor hourly urine output. *Give diuretics as prescribed.

Grief in Children: 5 to 9 years

- Child has difficulty concentrating. - Child begins to see death as permanent. - Child may feel responsible for the occurrence.

Grief in Children: 2 to 5 years

- Child may see death as reversible. - Regressive or aggressive behavior may occur. - Child has a sense of loss and is concerned about who will provide care.

Identify the five stages of death and dying.

- Denial - Anger - Bargaining - Depression - Acceptance

Autosomal Dominant Diseases

- Huntington's - Marfans - Polydactyl - Achondroplasia - Polycystic Kidney Disease *50% if one parent has the disease/trait (trait = disease in autosomal dominant)

Grief in Children: Birth to 1 year

- Infant has no concept of death. - Infant reacts to the loss of mother or caregiver

Hodgkin's disease:

- Is a neoplasm of lymphatic tissue. - Hallmark sign: giant, multinucleated cells (Reed-Sternberg cells) - Painless, firm, and movable adenopathy in the cervical and supraclavicular area. - Hepatosplenomegaly

Neuroblastoma

- Is a solid tumor found only in children. - Neural crest cells that develop into the sympathetic nervous system and the adrenal medulla. - Typically, the tumor infringes on adjacent normal tissue and organs. - Cells may excrete catecholamines and their metabolites. Urine samples will indicate elevated vanillylmandelic acid (VMA) levels. - Bone marrow aspiration will assist in determining marrow involvement.

X-Linked Recessive Diseases

- Muscular Dystrophy - Hemophilia A *Females are carriers (never have the disease) *Males have the disease (but can't pass it on) *50% chance daughters will be carriers (can't have disease) *50% chance sons will have the disease (not a carrier = can't pass it on) *This translates to an overall 25% chance that each pregnancy will result in a child that has the disease

Neutropenic (Immunosuppressed) Precautions

- No plants or flowers in room - No fresh veggies-cooked foods only - Avoid crowds and infectious persons - Meticulous hand washing and hygiene to prevent infection - Report fever > 100.5 (immunosuppressed pts may not manifest fever with infection - For the hospitalized neutropenic child, flowers or plants should not be kept in the room because standing water and damp soil harbor Aspergillus and Pseudomonas species, to which these children are very susceptible. Fruits and vegetables not peeled before being eaten harbor molds and should be avoided until the white blood cell count rises. The child is placed on a low-bacteria diet. Dressings are always changed using sterile technique. - Protective isolation procedures required in a neutropenic child.

Grief in Children: 1 to 2 years

- Toddler may see death as reversible. - Toddler may scream, withdraw, or become disinterested in the environment. - Grief response occurs only to the death of the significant person in the toddler's life.

A 4-year-old child diagnosed with leukemia is hospitalized for chemotherapy. The child is fearful of the hospitalization. Which nursing intervention should be implemented to alleviate the child's fears? 1. Encourage the child's parents to stay with the child. 2. Encourage play with other children of the same age. 3. Advise the family to visit only during the scheduled visiting hours. 4. Provide a private room, allowing the child to bring favorite toys from home.

1. Encourage the child's parents to stay with the child. *Although the preschooler already may be spending some time away from parents at a day care center or preschool, illness adds a stressor that makes separation more difficult. The child may ask repeatedly when parents will be coming for a visit or may constantly want to call the parents. Options 3 and 4 increase stress related to separation anxiety. Option 2 is unrelated to the subject of the question and, in addition, may not be appropriate for a child who maybe immunocompromised and at risk for infection.

The nurse analyzes the laboratory values of a child with leukemia who is receiving chemotherapy. The nurse notes that the platelet count is 19,500 mm3 (19.5 Â 109/L). On the basis of this laboratory result, which intervention should the nurse include in the plan of care? 1. Initiate bleeding precautions. 2. Monitor closely for signs of infection. 3. Monitor the temperature every 4 hours. 4. Initiate protective isolation precautions

1. Initiate bleeding precautions. *Leukemia is a malignant increase in the number of leukocytes, usually at an immature stage, in the bone marrow. It affects the bone marrow, causing anemia from decreased erythrocytes, infection from neutropenia, and bleeding from decreased platelet production (thrombocytopenia). If a child is severely thrombocytopenic and has a platelet count less than 20,000 mm3 (20.0 Â 109 /L), bleeding precautions need to be initiated because of the increased risk of bleeding or hemorrhage. Precautions include limiting activity that could result in head injury, using soft toothbrushes, checking urine and stools for blood, and administering stool softeners to prevent straining with constipation. In addition, suppositories, enemas, and rectal temperatures are avoided

The mother of a 4-year-old child tells the pediatric nurse that the child's abdomen seems to be swollen. During further assessment, the mother tells the nurse that the child is eating well and that the activity level of the child is unchanged. The nurse, suspecting the possibility of Wilms' tumor, should avoid which during the physical assessment? 1. Palpating the abdomen for a mass 2. Assessing the urine for the presence of hematuria 3. Monitoring the temperature for the presence of fever 4. Monitoring the blood pressure for the presence of hypertension

1. Palpating the abdomen for a mass *Wilms'tumor is the most common intraabdominal and kidney tumor of childhood. If Wilms' tumor is suspected, the tumor mass should not be palpated by the nurse. Excessive manipulation can cause seeding of the tumor and spread of the cancerous cells. Hematuria, fever, and hypertension are clinical manifestations associated with Wilms' tumor.

The nurse is monitoring a 3-year-old child for signs and symptoms of increased intracranial pressure (ICP) after a craniotomy. The nurse plans to monitor for which early sign or symptom of increased ICP? 1. Vomiting 2. Bulging anterior fontanel 3. Increasing head circumference 4. Complaints of a frontal headache

1. Vomiting *The brain, although well protected by the solid bony cranium, is highly susceptible to pressure that may accumulate within the enclosure. Volume and pressure must remain constant within the brain. Achange in the size of the brain, such as occurs with edema or increased volume of intracranial blood or cerebrospinal fluid without a compensatory change, leads to an increase in ICP, which may be life-threatening. Vomiting, an early sign of increased ICP, can become excessive as pressure builds up and stimulates the medulla in the brainstem, which houses the vomiting center. Children with open fontanels (posterior fontanel closes at 2 to 3 months; anterior fontanel closes at 12 to 18 months) compensate for ICP changes by skull expansion and subsequent bulging fontanels. When the fontanels have closed, nausea, excessive vomiting, diplopia, and headaches become pronounced, with headaches becoming more prevalent in older children

The nurse provides a teaching session to the nursing staff regarding osteosarcoma. Which statement by a member of the nursing staff indicates a need for information? 1. "The femur is the most common site of this sarcoma." 2. "The child does not experience pain at the primary tumor site." 3. "Limping, if a weight-bearing limb is affected, is a clinical manifestation." 4. "The symptoms of the disease in the early stage are almost always attributed to normal growing pains."

2. "The child does not experience pain at the primary tumor site." *Osteosarcoma is the most common bone cancer in children. Cancer usually is found in the metaphysis of long bones, especially in the lower extremities, with most tumors occurring in the femur. Osteosarcoma is manifested clinically by progressive, insidious, and intermittent pain at the tumor site. By the time these children receive medical attention, they may be in considerable pain from the tumor

A 4-year-old child is admitted to the hospital for abdominal pain. The mother reports that the child has been pale and excessively tired and is bruising easily. On physical examination, lymphadenopathy and hepatosplenomegaly are noted. Diagnostic studies are being performed because acute lymphocytic leukemia is suspected. The nurse determines that which laboratory result confirms the diagnosis? 1. Lumbar puncture showing no blast cells 2. Bone marrow biopsy showing blast cells 3. Platelet count of 350,000 mm3 (350 Â 109/L) 4. White blood cell count 4500 mm3 (4.5Â 109/L)

2. Bone marrow biopsy showing blast cells *Leukemia is a malignant increase in the number of leukocytes, usually at an immature stage, in the bone marrow. The confirmatory test for leukemia is microscopic examination of bone marrow obtained by bone marrow aspirate and biopsy, which is considered positive if blast cells are present. An altered platelet count occurs as a result of the disease, but also may occur as a result of chemotherapy and does not confirm the diagnosis. The white blood cell count may be normal, high, or low in leukemia. A lumbar puncture may be done to look for blast cells in the spinal fluid that indicate central nervous system disease.

A child undergoes surgical removal of a brain tumor. During the postoperative period, the nurse notes that the child is restless, the pulse rate is elevated, and the blood pressure has decreased significantly from the baseline value. The nurse suspects that the child is in shock. Which is the most appropriate nursing action? 1. Place the child in a supine position. 2. Notify the health care provider (HCP). 3. Place the child in Trendelenburg position. 4. Increase the flow rate of the intravenous fluids

2. Notify the health care provider (HCP) *In the event of shock, the HCP is notified immediately before the nurse changes the child's position or increases intravenous fluids. After craniotomy, a child is never placed in the supine or Trendelenburg position because it increases intracranial pressure (ICP) and the risk of bleeding. The head of the bed should be elevated. Increasing intravenous fluids can cause an increase in ICP.

The nurse is monitoring a child for bleeding after surgery for removal of a brain tumor. The nurse checks the head dressing for the presence of blood and notes a colorless drainage on the back of the dressing. Which intervention should the nurse perform immediately? 1. Reinforce the dressing. 2. Notify the health care provider (HCP). 3. Document the findings and continue to monitor. 4. Circle the area of drainage and continue to monitor.

2. Notify the health care provider (HCP). *Colorless drainage on the dressing in a child after craniotomy indicates the presence of cerebrospinal fluid and should be reported to the HCP immediately.

A 6-year-old child with leukemia is hospitalized and is receiving combination chemotherapy. Laboratory results indicate that the child is neutropenic, and protective isolation procedures are initiated. The grandmother of the child visits and brings a fresh bouquet of flowers picked from her garden, and asks the nurse for a vase for the flowers. Which response should the nurse provide to the grandmother? 1. "I have a vase in the utility room, and I will get it for you." 2. "I will get the vase and wash it well before you put the flowers in it." 3. "The flowers from your garden are beautiful, but should not be placed in the child's room at this time." 4. "When you bring the flowers into the room, place them on the bedside stand as far away from the child as possible."

3. "The flowers from your garden are beautiful, but should not be placed in the child's room at this time."

A diagnosis of Hodgkin's disease is suspected in a 12-year-old child. Several diagnostic studies are performed to determine the presence of this disease. Which diagnostic test result will confirm the diagnosis of Hodgkin's disease? 1. Elevated vanillylmandelic acid urinary levels 2. The presence of blast cells in the bone marrow 3. The presence of Epstein-Barr virus in the blood 4. The presence of Reed-Sternberg cells in the lymph nodes

4. The presence of Reed-Sternberg cells in the lymph nodes

Nursing assessments related to ALL:

A. Pallor, tiredness, weakness, lethargy due to anemia B. Petechia, bleeding, bruising due to thrombocytopenia C. Infection, fever due to neutropenia D. Bone joint pain due to leukemic infiltration of bone marrow E. Enlarged lymph nodes; hepatosplenomegaly F. Headache and vomiting (signs of CNS involvement) G. Anorexia, weight loss H. Lab data: bone marrow aspiration that reveals 80% to 90% immature blast cells

Nursing Plans and Interventions for ALL:

A. Recommend private room. B. Reverse isolation if prescribed. C. Provide child with age appropriate explanations for diagnostic tests, treatments, and nursing care. D. Examine child for infection of skin, needle-stick sites, dental problems E. Administer blood products as prescribed. F. Administer antineoplastic chemotherapy. G. Monitor for side effects of chemotherapeutic agents (see Table 4-37). 1. Vincristine (induction) 2. l-Asparaginase (induction) 3. Methotrexate (sanctuary and maintenance) 4. Mercaptopurine (6-MP (maintenance) H. Provide care directed toward managing side effects and toxic effects of antineoplastic agents. 1. Administer antiemetics as prescribed. 2. Monitor fluid balance. 3. Monitor for signs of infection. 4. Monitor for signs of bleeding. 5. Monitor for cumulative toxic effects of drugs: hepatic toxicity, cardiac toxicity, renal toxicity, and neurotoxicity. 6. Provide oral hygiene. 7. Provide small, appealing meals; increase calories and protein; refer to nutritionist. 8. Promote self-esteem and positive body image if child has alopecia, severe weight loss, or other disturbance in body image. 9. Provide care to prevent infection. I. Provide emotional support for family in crisis. J. Encourage family's and child's input and control in determining plans and treatment.

Bone Marrow Transplant (BMT):

Allogeneic: donor who matches the child's tissue type is found. That bone marrow is then given to the child. Syngeneic donor: the child has an identical twin. Autologous: aspiration of his or her bone marrow, which is then processed in the laboratory and frozen until that marrow needs to be infused back into the child.

Neutropenia:

An abnormally low number of neutrophils in the blood. The lower the absolute neutrophil count (ANC), the greater the risk of infection.

Leukemia:

Blast cells in the bone marrow