Chapter 37: The Child with a Cardiovascular/Hematologic Disorder
The nurse is caring for a toddler taking ferrous sulfate for severe iron-deficiency anemia. Which report by the parent is most concerning?
"I mix ferrous sulfate with milk in a bottle." Explanation: Ferrous sulfate may not be absorbed if taken with milk or tea, and if the parent mixes the medicine with milk in a bottle, there is also concern that if the child does not drink the entire amount of medication. Ferrous sulfate may be taken after meals to prevent gastrointestinal irritation. Dark stools are a common side effect of ferrous sulfate. Parents should be encouraged to brush the child's teeth thoroughly to prevent teeth staining
The parents of a 6-year-old child with idiopathic thrombocytopenic purpura (ITP) ask the nurse, "What causes this disease?" Which response by the nurse would be most appropriate?
"ITP is primarily an autoimmune disease in that the immune system attacks and destroys the body's own platelets, for an unknown reason." Explanation: Idiopathic thrombocytopenic purpura (ITP) is primarily an autoimmune disease, which is an acquired, self-limiting disorder of hemostasis characterized by destruction and decreased numbers of circulating platelets. Hemophilia A and hemophilia B are distinguished by the particular procoagulant factor that is decreased, absent, or dysfunctional. Iron deficiency anemia occurs when the body's iron stores are depleted. Hereditary spherocytosis (HS) is characterized by loss of surface area on the red blood cell membrane
A nurse is providing teaching to the parents of a child diagnosed with sickle cell anemia. The discussion is focused on precipitating factors for sickle cell crisis. Which statement by the parents requires the nurse to reinforce the teaching?
"Our family is taking a fun hiking trip up in the mountains next week." Explanation: High altitudes are a contributing factor for sickle cell crisis and should be avoided, as should flights in planes that are not pressurized. Extreme temperatures (hot or cold) are also triggers for a crisis so keeping warm during the winter is important. Dehydration and exposure to infection or other illness are precipitating factors for sickle cell crisis. Adequate hydration and keeping up with immunizations are imperative for health and wellness in a child diagnosed with sickle cell anemia
A couple is expecting a child. The fetus undergoes genetic testing and the couple discover the fetus has sickle cell disease. The couple ask the nurse how most commonly happens. Which statement is accurate for the nurse to provide?
"Sickle cell disease is passed to a fetus when both parents have the gene." Explanation: Sickle cell disease is an inherited disease. The recessive gene is passed from both parents who either have the disease or the trait. There is no need for further testing to determine the cause. There are no other ways to pass the disease other than through genetics. Informing the parents that the gene was passed from both parents is most informative. Sickle cell anemia is not a dominant disease, which is passed when only one parent has the gene, nor is caused by a random mutation
The nurse is caring for an infant girl with a suspected cardiovascular disorder. Which statement by the mother would warrant further investigation?
"The baby seems more comfortable over my shoulder." Explanation: The nurse should be alert to statements indicating that the baby seems to be more comfortable when she is sitting up or over her mother's shoulder than when she is lying flat. Grunting or rapid breathing would be a cause for concern. Drinking all of the bottle would be considered normal
The nurse is caring for children at a local hospital. Which child warrants immediate attention from the nurse?
1-week-old newborn whose oxygenation is not improving with oxygen Explanation: A newborn whose oxygenation is not improving with oxygen warrants immediate attention. Congenital heart disease needs to be suspected in the cyanotic newborn who does not improve with oxygen administration. In infants, peripheral edema occurs first in the face, then the presacral region, and then the extremities. This is an abnormal assessment finding that warrants follow-up but does not warrant immediate action. Clubbing is also an abnormal finding and warrants follow-up but not immediate action. It implies chronic hypoxia due to severe congenital heart disease. A temporal temperature of 101°F (38.3°C) is an abnormal assessment finding and warrants follow-up but not immediate action. Fever would suggest a possible infection
The nurse is developing a plan of care for an infant with heart failure who is receiving digoxin. The nurse would hold the dose of digoxin and notify the physician if the infant's apical pulse rate was:
80 beats per minute. Explanation: In an infant, if the apical pulse rate is less than 90 beats per minute, the dose is held and the physician should be notified
Which nursing diagnosis would best apply to a child with rheumatic fever?
Activity intolerance related to inability of heart to sustain extra workload Explanation: Acute rheumatic fever affects the joints, central nervous system, skin, and soft tissue. It causes chronic, progressive damage to the heart and valves. Children with rheumatic fever need to reduce activity to relieve stress on the heart and joints during the course of the illness. Rheumatic fever does not produce cardiomegaly nor does it interfere with respirations or the ability to oxygenate the body. Children with rheumatic fever may develop chorea. These movements are involuntary and are not related to hyperexcitability
Which nursing diagnosis would best apply to a child experiencing rheumatic fever?
Activity intolerance related to increased cardiac workload Explanation: TChildren will present with polyarthritis as multiple joints are inflamed and possibly have fluid accumulation. Fifty percent of the children present with carditis, usually as mitral valve insufficiency. As a result, the child experiences problems with activities due to increased cardiac workload. Chorea occurs in some children with rheumatic fever; however, it is not known if this manifestation will disturb the child's sleep. The prognosis for the child with rheumatic fever depends on the extent of myocardial involvement. Children with rheumatic fever may develop congestive heart failure; however, cardiomegaly is not a long-term effect of the disease. The prognosis for the child with rheumatic fever depends on the extent of myocardial involvement. The child is not at risk for self-directed violence because cerebral anoxia is not a manifestation of the disease
The nurse in the emergency department is caring for a 10-year-old female child with sickle cell crisis. Child rates pain 10 on a scale of 0 to 10. Vital signs: 99.8°F (37.6°C); heart rate, 122 beats/min; blood pressure, 92/50 mm Hg; respiratory rate, 26 breaths/min; oxygen saturation, 92% on room air. The nurse receives orders for the child. Click to highlight the order(s) that needs to be implemented immediately. Orders: Administer acetaminophen for headache or temperature greater than 101°F (38.3°C). Administer oxygen to maintain oxygen saturation greater than 95%. Start normal saline continuous intravenous (IV) infusion at 200 ml/hr. Administer 100 mcg/kg morphine IV for pain prn q4 hours. Initiate a regular diet as tolerated.
Administer oxygen to maintain oxygen saturation greater than 95%. Start normal saline continuous intravenous (IV) infusion at 200 ml/hr. Administer 100 mcg/kg morphine IV for pain prn q4 hours. Nursing interventions should always be prioritized according to the ABCs (airway, breathing, circulation). Because the child's oxygen saturation is only 92% on room air, the nurse should apply oxygen to achieve an oxygen saturation of 95% or greater. After implementing measures to ensure a patent airway, the nurse should address circulation. In sickle cell crisis, the red blood cells (RBCs) clump together blocking microcirculation, which causes pain due to ischemia. The nurse should start intravenous (IV) fluids to prevent clumping of the RBCs to improve circulation. The child is reporting pain that is a 10 out of 10. The child will require an intravenous (IV) opioid analgesic such as morphine. The child's temperature is slightly elevated at 99.8°F (37.6°C). This is most likely due to dehydration (water is cooling, and less water in the body will increase the temperature slightly). Therefore, acetaminophen does not need to be administered. Initiating a regular diet at this time is not a priority. The child's respiratory rate of 18 breaths/min are within normal limits.
The nurse is caring for a 10-year-old boy with hemophilia. He asks the nurse for suggestions about appropriate physical activities. Which activity would the nurse most likely recommend?
Baseball Explanation: Children with hemophilia should stay active. Good physical activities would be swimming, baseball, basketball, and bicycling (with a helmet). He would still need to be careful about falls and sliding into base. Intense contact sports like football, wrestling, and soccer should be avoided
What will the nurse include in the feeding plan for a breastfed infant with congenital heart disease?
Breastfeed with small, frequent feeds. Explanation: Some infants with congenital heart disease (CHD) tire easily and will require small, frequent breastfeeding to manage their energy and meet caloric needs. Their output and weight gain should be watched closely. Parents should anticipate more frequent weight checks in the first weeks, and a minimum of 6 to 8 wet diapers daily. Feeding every 4 hours will not promote the intake and growth required for an infant with CHD
Which nursing diagnosis would be most appropriate for a child with idiopathic thrombocytopenic purpura?
Ineffective tissue perfusion related to poor platelet formation Explanation: Idiopathic thrombocytopenic purpura (ITP) results from an immune response following a viral infection that produces antiplatelet antibodies. These antibodies destroy the platelets which cause petechiae, purpura, and excessive bleeding. ITP does not affect the kidneys. Breathing difficulties would not occur with decreased white blood cells. It occurs when there is decreased red blood cells. The child who develops ITP has no different immune system than other children who are healthy
After teaching a group of students about acute rheumatic fever, the instructor determines that the teaching was successful when the students identify which assessment finding?
Jerky movements of the face and upper extremities Explanation: Sydenham chorea is a movement disorder of the face and upper extremities associated with acute rheumatic fever. Janeway lesions, black lines, and Osler nodes are associated with infective endocarditis
A school-aged child is admitted to the hospital with a vaso-occlusive sickle cell crisis. Which measure in the child's care plan should be given priority?
Maintaining fluids through an intravenous line Explanation: Sickle cells clump together and prevent normal blood flow. This leads to tissue hypoxia. With a vaso-occlusive crisis, the cells are clumped together and prevent blood flow to the joint or organ. The blood with the clumped sickled cells is very viscous. Adequate hydration is crucial in relieving the problems of a vaso-occlusive crisis. The hydration dilutes the blood and decreases the viscosity. During a crisis the recommended fluid intake (IV and PO) is 150 ml/kg/day. During a vaso-occlusive crisis, the child has severe pain. The goal is to get the pain under control and increase blood flow. Range-of-motion exercises will add to the increased pain during this period of time, so should not be started until crisis in under control. The diet and hourly deep breaths are important, but they are not crucial to correcting the crisis
When providing care for a child immediately after a bone marrow aspiration, which nursing action is priority?
Monitor the site dressing and vital signs. Explanation: Monitoring vital signs and the dressing for signs of bleeding is a priority after bone marrow aspiration. Although providing pain medication, educating on handwashing, and allowing for therapeutic play are all important, these should only be performed after first stabilizing the child
The nurse is planning care for a child with idiopathic thrombocytopenic purpura. Which client education should be included?
Not to pick or irritate the nose Explanation: Idiopathic thrombocytopenic purpura (ITP) occurs as an immune response following a viral infection. It produces antiplatelet antibodies that destroy platelets. This leads to the classic symptoms of petechiae, purpura, and excessive bruising. Without adequate platelets, children bleed easily from lesions. If the child "picks" the nose, an area could be opened and bleeding could occur. Folic acid will have no effect on the disease process. The lesions are not itchy and are open or draining, so cold water washing and soothing lotions are not required
Which nursing diagnosis should the nurse identify as being the most appropriate for a child with idiopathic thrombocytopenic purpura?
Risk for bleeding related to insufficient platelet formation Explanation: Idiopathic thrombocytopenic purpura is the result of a decrease in the number of circulating platelets in the presence of adequate megakaryocytes, which are precursors to platelets. Because bleeding can occur with this disease process, the diagnosis most appropriate for the client at this time is risk for bleeding related to insufficient platelet formation. Reduced numbers of platelets would not increase the client's risk for infection. Reduced numbers of platelets does not increase the client's risk for renal impairment. Reduced risk of platelets will not lead to an ineffective breathing pattern
When conducting a physical examination of a child with suspected Kawasaki disease, which finding would the nurse expect to assess?
Strawberry tongue Explanation: Dry, fissured lips and a strawberry tongue are common findings with Kawasaki disease. Acne, hirsutism, and striae are associated with anabolic steroid use. Malar rash is associated with lupus. Café au lait spots are associated with neurofibromatosis
The nurse is caring for a school-age child with reports of generalized joint pain and a pharyngitis. During assessment, the nurse notes a cardiac murmur. Which action by the nurse is priority?
Swab throat for culture. Explanation: A child with generalized joint pain, pharyngitis, and murmur is exhibiting signs of rheumatic fever. A priority action is to obtain a throat culture to verify presence of a group A streptococcus infection and then administer penicillin. Assessing for a rash is minimally helpful as there is enough assessment data to obtain a throat culture. A high C-reactive protein is an indicator of an active infection, but it will not identify the source of the infection and the necessary pharmacologic therapy
A nursing instructor is preparing for a class about the structural and functional differences in the cardiovascular system of infants and children as compared to adults. What would the instructor include in the class discussion?
The heart's apex is higher in the chest in children younger than the age of 7 years. Explanation: In infants and children younger than age 7 years, the heart lies more horizontally, resulting in the apex lying higher in the chest. Right ventricular function predominates at birth, and over the first few months of life, left ventricular function becomes dominant. A normal infant's blood pressure is about 80/40 mm Hg and increases over time to adult levels. Between the ages of 1 and 6 years, the heart is four times the birth size; between 6 and 12 years of age, the heart is 10 times its birth size
A 9-month-old infant with iron-deficiency anemia is given ferrous sulfate therapy. Which assessment would best help the nurse determine that the infant is actually taking it daily?
The stools will appear black. Explanation: Oral iron supplements are dark in color because the iron is pigmented. As a result of digestion of this pigment, the stools of an infant taking iron will be dark to black. Taking iron supplements will cause constipation, not diarrhea. After treatment with iron, the reticulocyte count should be increased, not decreased. Children with iron deficiency are tired and many times irritable. With correction of the deficiency, the infant should be less irritable and have more energy
To prevent infective endocarditis in the child with an artificial heart valve, the nurse teaches parents to:
administer prophylactic antibiotics before dental work. Explanation: Dental procedures may allow organisms to enter the child's bloodstream and grow on the artificial valve. This makes excellent oral hygiene also important. Unexplained fevers should be discussed with the child's health care provider and not automatically treated at home. Raw fruits and vegetables and household pets are not a particular threat to this child
The nurse will select which meal as the best choice for a child with iron-deficiency anemia?
cheeseburger, broccoli, and fresh strawberries Explanation: Children with iron-deficiency anemia require diets rich in iron and vitamin C (vitamin C enhances iron absorption). Meats are excellent sources of iron. Broccoli is a good source of iron, and strawberries are a good source of vitamin C. To help the body absorb the most iron from the meal, tea and foods rich in calcium (such as milk and cheese) should be avoided
A 12-year-old child is admitted to the hospital with a diagnosis of sickle cell crisis. The nurse has completed an assessment and is creating a plan of care. What aspect of the plan of care is most important to the client's outcome?
increasing the daily fluid intake Explanation: Hydration is paramount to resolving a sickle cell crisis. Administering analgesics on a set schedule versus an as-needed schedule will help keep the pain at a manageable level. The hemoglobin level during a crisis can be as low as 6 g/dL (60 g/L). To get to 10 g/dL (100 g/L), the client would need to be transfused. Using age-appropriate distractions as pain relief may not be effective during a crisis initially
The nurse sees a school-aged child in an ambulatory setting because of rheumatic fever. Which of the following would the nurse expect to find revealed by the health history?
knee pain, abdominal rash, subcutaneous nodules Explanation: Classic signs of rheumatic fever are joint pain, a rash on the trunk, and subcutaneous nodules near major joints
To prevent further sickle cell crisis, the nurse would advise the parents of a child with sickle cell anemia to:
notify a health care provider if the child develops an upper respiratory infection. Explanation: Infections caused by the Streptococcus pneumoniae can be lethal to a child with sickle cell, because they can cause overwhelming sepsis or meningitis. By 2 months of age the child should be started on Penicillin V as prophylaxis against pneumococcal infections. The child should receive the 7 valent pneumococcal series in infancy. After 2 years of age the child should receive the 23 valent pneumococcal vaccine. He or she should also be immunized against meningitis. Participating in strenuous activities such as running and limiting the amount of fluids leads to a reduction of oxygen and dehydration. This can lead to the increased sickling of cells. The anemia of sickle cell disease is not the result of iron deficiency. It is the result of the abnormal shape of the red blood cell. Administering iron will not correct the anemia
The nurse is implementing the plan of care for a child with acute rheumatic fever. What treatment(s) would the nurse expect to administer if prescribed? Select all that apply. penicillin corticosteroids nonsteroidal anti-inflammatory drugs digoxin intravenous immunoglobulin
penicillin corticosteroids nonsteroidal anti-inflammatory drugs A full 10-day course of an antibiotic, such as penicillin or equivalent, is used. Anti-inflammatory agents, such as corticosteroids and nonsteroidal anti-inflammatory drugs, are also used in the treatment of acute rheumatic fever. Digoxin, an antiarrhythmic agent, a is used to treat heart failure, atrial fibrillation, atrial flutter, and supraventricular tachycardia. Intravenous immunoglobulin, an immunoglobulin therapy, is used to treat Kawasaki disease.
The nurse is assessing a child and notices pinpoint hemorrhages appearing on several different areas of the body. The hemorrhages do not blanch on pressure. The nurse documents this finding as:
petechiae. Explanation: Petechiae are pinpoint hemorrhages that occur anywhere on the body and do not blanch with pressure. Purpura are larger areas of hemorrhage in which blood collects under the tissues and appear purple in color. Ecchymosis refers to areas of bruising. Poikilocytosis refers to the variation in the size and shape of the red blood cells commonly found in children with thalassemia
A nurse is preparing a 7-year-old girl for bone marrow aspiration. Which site should she prepare?
slows and strengthens the heartbeat Explanation: Digoxin, a cardiac glycoside made from digitalis, acts directly on the heart to increase the contractility of the myocardium and the force of contraction to slow the heart rate. Digoxin does not increase the heart rate, thicken the walls of the myocardium, or prevent subacute bacterial endocarditis
An infant is prescribed digoxin. What should the nurse explain to the parents regarding the action of this medication?
slows and strengthens the heartbeat Explanation: Digoxin, a cardiac glycoside made from digitalis, acts directly on the heart to increase the contractility of the myocardium and the force of contraction to slow the heart rate. Digoxin does not increase the heart rate, thicken the walls of the myocardium, or prevent subacute bacterial endocarditis
A nurse is caring for a child who is experiencing heart failure. Which assessment data was most likely seen when initially examined?
tachycardia Explanation: If a child were experiencing heart failure, the most likely sign of this would be tachycardia, not bradycardia. The child may also experience hepatomegaly or oliguria, not splenomegaly or polyuria
