Peds Exam 2 chapters 23,24 and 25

What is considered a mixed cardiac defect? a. Pulmonic stenosis b. Atrial septal defect c. Patent ductus arteriosus d. Transposition of the great arteries

D. Transposition of the great arteries Transposition of the great arteries allows the mixing of both oxygenated and unoxygenated blood in the heart. Pulmonic stenosis is classified as an obstructive defect. Atrial septal defect and patent ductus arteriosus are classified as defects with increased pulmonary blood flow.

A cardiac assessment is required to determine if a child's physical symptoms are related to possible heart disease. The nurse is proceeding to auscultation techniques. When observing the nursing student perform this assessment, which action would indicate that additional training was required? a. documentation of heart sounds in reference to anatomical location b. determination that there is no evidence of carotid bruits c. calculation of heart rate d. Ascertaining whether there is evidence of splenic enlargement

d. Ascertaining whether there is evidence of splenic enlargement. Evidence of splenic enlargement requires palpation as an assessment technique. All of the other options are in-line with auscultation techniques.

B-thalassemia minor

} Heterozygous form... only one parent with gene } Asymptomatic: Chronic MILD Microcytic Anemia } Accidental discovery } Normal physical exam

Iron deficiency anemia

- A production problem - Why?: Inadequate supply of Fe. o Fe an important component of Hgb o Inadequate amount of Fe-> inadequate amount of Hgb o Most prevalent dietary disorder in the U.S. o Children most @ risk: o Children 6 months - 2 yrs. o Adolescent females o Infants without Fe fortified formula o Children with milk intake > 24 oz/day o Children who drink large volumes of fruit juice o Children with poor appetite o Children who eat junk food all day o PROLONGED ANEMIA LEADS TO GROWTH RETARDATION AND DEVELOPMENTAL DELAY o Signs & symptoms: o Often asymptomatic o Pallor o Tachycardia or new murmur o Listless & Irritable o Low grade fever o Shortness of breath o Breast fed babies: o Fe-rich cereals after 6 months o Non breastfed babies: o Fe-fortified formula o Children: o Beef, pork chicken, liver, fish, shellfish o Cooked beans o Enriched breads, rice, pasta, tortillas o Leafy greens o DECREASE JUNK FOOD! o Oral iron supplement o Take between meals unless causes stomach upset. o Absorbed best if taken with Vitamin C. o Calcium decreases absorption. o Can cause staining, so use straw o Remember... it is toxic in excess! o Every year... 3,500 Fe poisonings/yr o Screenings o Recommended routinely @: o 9 mos. - 1 yr. o during adolescence (especially females) o if at risk with dietary history

3 most common types of brain tumors in children

- Most common types in kids: • Astrocytoma • Invades the cerebral hemispheres & the cerebellum • Medulloblastoma • Invade the cerebellum • Ependymoma - Rare

Congenital anemia's

1. Beta Thalassemia Anemia (Production AND destruction) 2. Sickle Cell Anemia

In taking care of a pediatric oncology patient, which diagnostic finding would indicate a critical concern for the development of infection? A. Absolute neutrophil count of 250 mm3 B. Temperature of 99.2 degrees Fahrenheit C. White blood cell count 7,000 mm3 D. Platelet count 100,000 mm3

A. Absolute neutrophil count of 250 mm3 An absolute neutrophil count of less than 500 mm3 is of critical concern as it indicates the potential for overwhelming infection. None of the other measurement parameters are reflective of this fact.

If a child is being treated with ACE inhibitors as part of the therapeutic regimen for heart failure, which observation is noted would alert the nurse to a potential interaction? A. Diuretic therapy with Aldactone B. Child complains of being slightly dizzy at times C. Maintaining normal urine output D. Blood pressure monitoring at lower end of normal range

A. Diuretic therapy with Aldactone The use of ACE inhibitors in combination with Aldactone, which is a potassium sparing inhibitor can lead to potential hyperkalemia. As such this type of diuretic therapy should not be used. ACE inhibitors typically are not associated with dizziness but continued monitoring for this presentation should be included. Normal urine output is a favorable sign. ACE inhibitors can cause hypotension so continued monitoring would be needed at this point.

What procedure uses high-frequency sound waves obtained by a transducer to produce an image of cardiac structures? a. Echocardiography b. Electrocardiography c. Cardiac catheterization d. Electrophysiology

A. Echocardiography Echocardiography uses high-frequency sound waves. The child must lie completely still. With the improvements in technology, a diagnosis can sometimes be made without cardiac catheterization. Electrocardiography is an electrical tracing of the depolarization of myocardial cells. Cardiac catheterization is an invasive procedure where a catheter is threaded into the heart, a contrast medium is injected, and the heart and its vessels are visualized. Electrophysiology is an invasive procedure where catheters with electrodes record the impulses of the heart directly from the conduction system.

A child with lymphoma is receiving extensive radiotherapy. What is the most common side effect of this treatment? A. Fatigue B. Seizures C. Neuropathy D. Lymphadenopathy

A. Fatigue Fatigue is the most common side effect of radiotherapy. For children, the fatigue may be distressing because they cannot keep up with their peers. Seizures are unlikely, because irradiation would not usually be cranial for lymphoma. Neuropathy is a side effect of certain chemotherapeutic agents but not of radiotherapy. Lymphadenopathy is one of the findings of lymphoma, not a side effect of radiotherapy.

What is the most appropriate action to stop an occasional episode of epistaxis? A. Have the child sit up and lean forward. B. Apply ice under the nose and above the lip. C. Have the child lie down quietly with the feet elevated. D. Apply continuous pressure to the nose with the thumb and forefinger for at least 1 minute.

A. Have the child sit up and lean forward. Sitting up and leaning forward is the position used to prevent the child from aspirating blood. Pressure, not ice, is indicated for an occasional episode of epistaxis. Lying the child down with the feet elevated can potentially lead to aspiration. Continuous pressure for 10 minutes is recommended; 1 minute would not be long enough.

The pediatric nurse is performing a well child assessment. Which finding if noted would require further investigation? A. Palpation of an abdominal mass without pain expression. B. No report of pain or tenderness in arms or legs. C. Buccal mucosa pink and intact. D. Grey appearance of tympanic membrane on otoscopic exam.

A. Palpation of an abdominal mass without pain expression. In a pediatric patient detection of an abdominal mass, regardless of pain expression requires further diagnostic work up as it may be evidence of Wilm's tumor. All of the other findings represent normal variations and as such do not require further investigation.

What are the most common signs and symptoms of leukemia related to bone marrow involvement? A. Petechiae, infection, fatigue B. Headache, papilledema, irritability C. Muscle wasting, weight loss, fatigue D. Decreased intracranial pressure, psychosis, confusion

A. Petechiae, infection, fatigue Petechiae, infection, and fatigue are signs of infiltration of the bone marrow. Petechiae occur from a lowered platelet count, infection occurs from the depressed number of effective leukocytes, and fatigue occurs from the anemia. Headache, papilledema, irritability, muscle wasting, weight loss and fatigue are not signs of bone marrow involvement. Decreased intracranial pressure, psychosis, and confusion are not signs of bone marrow involvement.

What is an early sign of congestive heart failure that the nurse should recognize? A. Tachypnea B. Bradycardia C. Inability to sweat D. Increased urinary output

A. Tachypnea Tachypnea is one of the early signs of congestive heart failure that should be identified. Tachycardia at rest, dyspnea, retractions, and activity intolerance are other physical signs and symptoms. Tachycardia, not bradycardia, is one of the symptoms suggestive of congestive heart failure. The child may be diaphoretic if experiencing congestive heart failure. There will usually be decreased urinary output in a child experiencing congestive heart failure.

What is the most important nursing consideration when caring for a child with sickle cell anemia? A. Teach the parents and child how to minimize crises. B. Refer the parents and child for genetic counseling. C. Help the child and family to adjust to a short-term disease. D. Observe for complications of multiple blood transfusions.

A. Teach the parents and child how to minimize crises. Children and their families need specific instructions on how to minimize crises, including preventing infections; maintaining adequate hydration; and addressing environmental concerns, such as avoidance of extreme cold. Genetic counseling is important, but teaching care for the child is a priority. Sickle cell anemia is a long-term, chronic illness. Multiple blood transfusions are an option for some children with sickle cell disease. The priority is that the child and the parents are properly prepared to manage the chronic disease.

The nurse is preparing to give digoxin (Lanoxin) to a 9-month-old infant. The nurse checks the dose; 4 ml of the drug is to be drawn up. Based on the nurse's knowledge of this medication and safe pediatric dosages, the most appropriate action by the nurse is A. do not draw-up dose; suspect dosage error. B. mix dose with juice to disguise its taste. C. check heart rate; administer dose by placing it to the back and side of mouth. D. check heart rate; administer dose by letting infant suck it through a nipple.

A. do not draw-up dose; suspect dosage error. Digoxin is often prescribed in micrograms. Rarely is more than 1 ml administered to an infant. As a potentially dangerous drug, digoxin has precise administration guidelines. Some institutions require that digoxin dosages be checked with another professional before administration. The nurse has drawn up too much medication and should not give it to the child. Administration procedures as described are correct, but too much medication is prepared, so it should not be given to the child.

Nursing considerations related to the administration of chemotherapeutic drugs include A. many chemotherapeutic agents are vesicants that can cause severe cellular damage if the drug infiltrates. B. good hand washing is essential when handling chemotherapeutic drugs, but gloves are not necessary. C. infiltration will not occur, unless superficial veins are used for the intravenous infusion. D. anaphylaxis cannot occur, because the drugs are considered toxic to normal cells.

A. many chemotherapeutic agents are vesicants that can cause severe cellular damage if the drug infiltrates. Chemotherapeutic agents can be extremely damaging to cells. Nurses experienced with the administration of vesicant drugs should be responsible for giving these drugs and prepared to treat extravasations if necessary. Gloves are worn to protect the nurse when handling the drugs, and the hands should be thoroughly washed afterward. Infiltration and extravasations are always a risk, especially with peripheral veins. Anaphylaxis is a possibility with some chemotherapeutic and immunologic agents, including asparaginase (Elspar).

Critical safety considerations that must be included if parenteral iron injections are used as part of therapy include Select all that apply. A. type and cross match. B. no massage following injection. C. multiple injections are preferred over intravenous route. D. no more than 1 ml should be given via injection. E. there is no need for a test dose administration if administered intravenously.

A. no massage following injection., D. no more than 1ml should be given via injection There is no need to perform a type and cross for iron replacement therapy. Administration via injection is done into a large muscle mass using Z track technique with no massage following. Preference is for intravenous route over intramuscular route if more than one injection is needed. No more than 1 ml is given via injection and a test dose is recommended if using intravenous route to high potential for allergic reaction.

Astrocytoma

An astrocytoma usually involves the cerebellum and the cerebral hemispheres. The exact location of the tumor will determine the symptoms. Size plays a big part in that also. In general, all brain tumors usually cause headaches, nausea, vomiting, and dizziness. Depending on size and location, the child might exhibit gait disturbances, issues with balance, and interference with speech and/or vision and/or hearing. Astrocytoma are graded by size, location, and innervation. Originate in the star shaped cells of the brain called astrocytes • As with all brain cancers, the tumor causes compression, invasion & destruction of brain parenchyma - Graded from 0 to 4 (4 being most severe)

Amemia

Anemia } It is not a specific disease in itself } Most common hematologic disorder of infancy & childhood Types: } Iron Deficiency Anemia } B-Thalassemia Anemia } Sickle Cell Anemia } Aplastic Anemia } Describes a condition in which: } The # of RBC's is REDUCED below normal values for age and/or } The Hgb concentration WITHIN the RBC is reduced below normal values for age. } With anemia, the O2 carrying capacity of blood is decreased...

Anemia labs

Anemia Labs } MCV= Mean Corpuscular Volume (size) Decreased MCV means RBC's are smaller than they should be. Called microcytic. Increased MCV means RBC's are larger than they should be. Called macrocytic. } MCH=Indicates the weight of hemoglobin in the RBC regardless of size. } In macrocytic anemias, the MCH is elevated and it is decreased in microcytic and hypochromic anemias. } MCHC = Mean corpuscular hemoglobin concentration } Represents the intensity of color. } Normal RBC's are red in color with an area of central pallor. } Decreased MCH means RBC's are pale. Called hypochromic. } Increased MCH means RBC's are a deeper red. Called hyperchromic. Reticulocyte count (called retic for short) Ø DIRECT measurement of production of RBC's in bone marrow. Ø Reticulocytes are immature RBC's. Ø RBC's normally enter the circulation as reticulocytes and attain the mature form of erythrocytes in 1-2 days. Ferritin. Ø Iron is stored in the body as ferritin. A ferritin level is the measure of the iron in the body's iron "store house". Hgb, Hct... inexpensive... first line... acceptable for screening, but not for diagnosis RDW Indicates the RBC distribution width. Ø The size (width) differences of RBCs. Ø Useful in predicting anemia early before MCV changes and before signs and symptoms occur. Ø Elevated RDW indicates iron deficiency anemia, pernicious anemia and certain homozygous hemoglobinopathies.

With regard to incidence of childhood cancer, which statement is accurate? A. In children there is a high incidence of cancer. B. Despite a low incidence, there is high morbidity in children under the age of 15. C. Gender does not affect incidence of childhood cancers. D. Higher incidence in found in African American children as compared to Caucasians.

B. Despite a low incidence, there is high morbidity in children under the age of 15. Despite a lower incidence of childhood cancer, there is a higher morbidity associated with specific age groups. Different subtypes of cancer are affected by gender, age and ethnicity. A higher incidence of cancers are found in Caucasian children as compared to African American children.

A physician suspects that a child may have congenital cardiac disease. Which noninvasive diagnostic procedure would help to confirm the possibility of heart disease? A. EKG B. Echocardiogram C. Chest x-ray D. Pulse oximetry

B. Echocardiogram An echocardiogram is the most common test used to identify either a cardiac anomaly or evidence of heart disease. EKG provides evidence of electrical system conduction. Pulse oximetry provides information relative to perfusion. And a chest x-ray focuses on lungs and airway exchange, it may not be sensitive and specific to determine cardiac pathology.

A child is status post hematopoietic stem cell transplantation (HSCT) and is preparing for discharge home. Based on the nurse's knowledge of HSCT, which concepts are important to include in the discharge teaching plan of care? Select all that apply. A. Preparing the child to return to school within 6 weeks B. Keeping the child on a high-calcium diet C. Avoiding live plants and fresh vegetables D. Avoiding influenza vaccinations E. Practicing good hygiene

B. Keeping the child on a high-calcium diet, C. Avoiding live plants and fresh vegetables, D. Practicing good hygiene Children should have a diet high in calcium or be placed on calcium supplements to reduce the risk of osteopenia. Live plants and fresh vegetables should be avoided because they carry bacteria. Practicing good hand hygiene is essential to prevent the spread of infection. Children cannot return to school for 6-12 months after HSCT. Either in-hospital or home schooling is required. Children and their families should be encouraged to get yearly influenza vaccination.

What is appropriate mouth care for a toddler with mucosal ulceration related to chemotherapy? A. Lemon glycerin swabs for cleansing B. Mouthwashes with normal saline C. Mouthwashes with hydrogen peroxide D. Local anesthetic such as viscous lidocaine before meals

B. Mouthwashes with normal saline Normal saline mouthwashes are the preferred mouth care for this age group. The rinse will keep the mucosal surfaces clean without adverse effects on mucosa or problems if the child swallows the rinse. Lemon glycerin swabs can irritate eroded tissue and can decay teeth. Hydrogen peroxide delays healing by breaking down protein. Viscous lidocaine is not recommended for toddlers, because it depresses the gag reflex and the child may have resultant aspiration.

An example of a disease process with underlying immune adaptation l potentially leading to a cancer diagnosis is? A. Fanconi anemia B. Wiskott Aldrich syndrome C. Klinefelter syndrome D. Retinoblastoma

B. Wiskott Aldrich syndrome Wiskott Aldrich syndrome is an example of an immunodeficiency state may place the individual at increased risk to develop certain cancers. Fanconi anemia and Klinefelter syndrome are examples of chromosomal abnormalities which can potentially lead to development of cancer. Retinoblastoma is an example of "two-hit" hypothesis of inheritance leading to development of cancer states.

After a patient returns from cardiac catheterization, the nurse notes that the pulse distal to the catheter insertion site is weaker (+1). The most appropriate nursing intervention is to A. elevate the affected extremity. B. document the findings and continue to monitor. C. notify the health care provider of the finding. D. apply warm compresses to the insertion site.

B. document the findings and continue to monitor. The pulse distal to the catheter insertion site may be weaker for the first few hours after catheterization. It should gradually increase in strength. The extremity is kept straight and immobile, but elevation is not necessary. Because a weaker pulse is an expected finding, the nurse should document it and continue to monitor it. There is no need to notify the physician. The insertion site is kept dry. Warm compresses would increase the risk of bleeding from the insertion site.

The school nurse is explaining to a child's kindergarten teacher that the child is allergic to peanuts. The nurse should include information that A. the child will most likely outgrow the allergy soon. B. the child should have an injectable epinephrine cartridge available at all times. C. the child allergic to peanuts can usually have peanut butter, but not whole peanuts. D. the child usually only shows skin signs such as hives when allergic.

B. the child should have an injectable epinephrine cartridge available at all times. Exposure to peanuts can result in a severe allergic, potentially life-threatening reaction, such as anaphylaxis and shock. Immediate treatment to prevent such reactions includes the injection of epinephrine; therefore, this should be available at all times wherever the child is within the school premises. Peanut allergies may be lifelong. Children allergic to peanuts are allergic to all peanut products, whole and processed. They should have no peanut-containing products at all. The signs and symptoms of an allergic reaction to peanuts may vary from individual to individual.

Beta thhalassemia anemia

Beta Thalassemia Anemia } People of Italian and Greek descent are the most common carriers of the gene. } Because of this, it is sometimes called Mediterranean Anemia Beta thalassemia Major (Cooley anemia) } Homozygous form: ◦ Gene must come from both parents ◦ Evident in infancy } Cause: } Defective synthesis of HbA } Structurally impaired RBC's } Shortened life span of RBC's } Clinical Manifestations: } Poor feeding, FTT, unexplained fever, splenomegaly, pallor } With Progressive Anemia... } Signs of chronic hypoxia: } HA } Precordial & bone pain } Decreased exercise tolerance } Listlessness & anorexia } Small stature } Delayed sexual maturation } Prominent frontal bones on enlarged head } Protrusion of the lip & upper central incisors } Objectives of treatment: } To maintain sufficient Hgb levels to prevent bone marrow expansion & the resulting bony deformities } To provide sufficient RBC's to support normal growth & normal physical activity } FREQUENT TRANSFUSIONS! } Goal to maintain Hgb level >9.5 } May require a transfusion every 3-5 weeks } Splenectomy: } If splenomegaly becomes severe

The parents of a child with sickle cell anemia (SCA) are concerned about subsequent children having the disease. Which response by the nurse is most accurate? A. "SCA is not inherited." B. "All siblings will have SCA." C. "There is a 25% chance of a sibling having SCA." D. "There is a 50% chance of a sibling having SCA."

C. "There is a 25% chance of a sibling having SCA." SCA is inherited as an autosomal recessive disorder. In this inheritance pattern, there is a 25% chance that each subsequent child will have the disorder. SCA is an inherited hemoglobinopathy. In autosomal recessive disorders, there is a chance that 25% of the children

What is an important nursing responsibility when a dysrhythmia is suspected? a. Order an immediate electrocardiogram. b. Count the radial pulse every 1 minute for five times. c. Count the apical pulse for 1 full minute, and compare the rate with the radial pulse rate. d. Have someone else take the radial pulse simultaneously with the apical pulse.

C. Count the apical pulse for 1 full minute, and compare the rate with the radial pulse rate. This is the nurse's first action. If a dysrhythmia is occurring, the radial pulse rate may be lower than the apical pulse rate. This may be indicated after conferring with the practitioner. The radial pulse rate needs to be compared with the apical pulse rate. It does not need to be counted for 1 minute five times. Only one nurse is needed to carry out this action.

The school nurse is caring for a boy with hemophilia who fell on his arm during recess. What supportive measures should the nurse use until factor replacement therapy can be instituted? A. Apply warm, moist compresses. B. Apply pressure for at least 1 minute. C. Elevate the area above the level of the heart. D. Begin passive range-of-motion unless the pain is severe.

C. Elevate the area above the level of the heart. The initial response should include elevation of the arm to minimize bleeding. Cold should be applied to the arm. This will aid in vasoconstriction, minimizing blood loss. Pressure is effective in small areas but would not be as effective for an extremity. Passive range-of-motion is not recommended. The child can perform active range-of-motion after the bleeding episode has resolved.

A pediatric oncology patient is undergoing chemotherapy. Which treatment option would the nurse anticipate being included in the plan of care in order to prevent the development of sterile hemorrhagic cystitis? A. Restrictive fluid intake. B. Inclusion of dairy foods in the diet. C. Implementing a frequent voiding plan throughout the course of the day to the patient. D. Limiting mobility during course of chemotherapy.

C. Implementing a frequent voiding plan throughout the course of the day to the patient. Providing a frequent voiding plan to encourage the patient to void upon urge, immediately upon arising, before bedtime and one nighttime void will help to prevent possibility of urinary stasis. Encouraging fluid intake rather than restricting fluid is the mainstay of treatment. Dairy foods in the diet provide no effective treatment against the development of sterile hemorrhagic cystitis. Similarly, limiting mobility is not indicated.

The school nurse is discussing prevention of acquired immunodeficiency syndrome (AIDS) with some adolescents. Which statement is appropriate to include? A. The virus is easily transmitted. B. The virus is transmitted only through blood. C. Intravenous drug users should not share needles. D. Condoms should be used if a person is sexually active and homosexual.

C. Intravenous drug users should not share needles. Human immunodeficiency virus (HIV) is spread through blood and body fluids. Intravenous needles that have been used should not be shared. They may be contaminated with the virus. The virus is not easily transmitted. It requires direct contact with blood or body fluids on a nonintact skin surface. Body fluids may also transmit the virus. Condoms should be used for both heterosexual and homosexual sex.

When treating nausea and vomiting as a side effect of chemotherapy and/or radiotherapy, ondansetron (Zofran) is the preferred drug of choice because? A. It has a shorter onset of action. B. It can be administered via several different routes. C. It does not cause extrapyramidal side effects. D. It has no adverse side effects if administered appropriately.

C. It does not cause extrapyramidal side effects. Zofran is a 5-hydroxytryptamine-3 receptor antagonist and is considered the antiemetic of choice for oncology patients as it produces no extrapyramidal side effects. Pharmacodynamics and pharmacokinetic features aside, the preference for this medication is due to producing no extrapyramidal side effects. Any medication even if administered properly has the potential to cause side effects. The ability to administer via different routes does not indicate a preferred drug choice.

Pediatric oncology patients are affected by medical management of their respective disease process and yet it is critical to include health promotion measures as part of their overall care. Which health promotion is not indicated in the plan of care? A. Continuation of dental hygiene treatment plan consistent with developmental age of child. B. Family members should receive live measles, mumps and rubella vaccinations as warranted. C. No treatment should be given if the patient has been exposed to varicella. D. The patient should not receive live attenuated vaccines during the course of chemotherapy protocol.

C. No treatment should be given if the patient has been exposed to varicella. If a pediatric oncology patient has been exposed to varicella, dependent on the time frame either varicella immune zoster immunoglobulin should be administered (within 96 hours of exposure) and/or treatment with antiviral agents should be provided if the patient develops varicella. This treatment is indicated as the development of varicella can lead to increased morbidity and mortality. All of the other options should be included in a health promotion plan of care.

Sickle cell disease (SCD) occurs through a genetic mutation. Based on the understanding of this genetic form of transmission, the nurse understands that A. there are no carrier states associated with this disease. B. the disease is transmitted as part of a sex-linked mutation. C. SCD refers to a group of congenital disease expressions. D. it is a relatively uncommon disease as it is expressed as an autosomal recessive gene trait.

C. SCD refers to a group of congenital disease expressions. SCD refers to a group of heredity disease states in which there is variants exhibited in both heterozygous and homozygous expressions. It is expressed as an autosomal recessive trait and as such there are carrier states. It is not transmitted as a sex-linked mutation. It is one of the most common genetic disorders globally.

A young pediatric oncology patient has stomatitis. Which intervention if observed by the charge nurse would warrant immediate action? A. The nurse assigned to the patient was offering mouth care using a sponge toothbrush. B. The nurse offers the patient frequent mouth rinses. C. The nurse is preparing to use viscous lidocaine to offer pain relief. D. The nurse administers sucralfate as ordered.

C. The nurse is preparing to use viscous lidocaine to offer pain relief. Use of viscous lidocaine is contraindicated in mucosal alterations as it can lead to potential aspiration and seizure activity. All of the other interventions are appropriate and can be used for symptomatic relief of stomatitis.

A pediatric patient has been diagnosed with leukemia and presents with a white blood cell (WBC) count of 80,000 mm3. In teaching a group of nursing students about the disease process, how would the nursing instructor describe the proliferation of white blood cells and their ability to fight off infection? A. The increase in WBC provides protection against viral infections but not bacterial infections. B. Although the WBC count is elevated, there are limited blast cells which leads to an increased likelihood that the patient will develop an infection. C. There is an increase in immature cells which reduce the body's ability to fight off infection. D. Although the WBC count is elevated, they are overwhelmed with mature cells that predispose the individual to develop an infection.

C. There is an increase in immature cells which reduce the body's ability to fight off infection. In leukemia, WBC count is elevated with an increase in blast or immature cells which limit the functional ability of WBCs being able to fight off infection.

A child has been diagnosed with aplastic anemia and undergoing therapeutic treatment. Therapeutic therapy would focus on A. palliative treatment to maintain comfort. B. initiation of steroid therapy. C. anticipation of bone marrow transplant. D. asking parents if they want to consider organ donation.

C. anticipation of bone marrow transplant. Although a clinical diagnosis of aplastic anemia can lead to increased morbidity and mortality treatment measures focusing on immunosuppressive therapy, removal of potential exacerbating etiology, and bone marrow replacement. Palliative treatment methods may be included but they are not the mainstay of therapeutic management. Steroid therapy is not indicated as that may lead to an increased susceptibility to infection. Asking the parents about organ donation at this time may cause considerable distress and anxiety.

A child has frequent nose bleeds without warning producing varying amount of blood. Inspection of the nose area reveals irritated mucosa but no evidence of picking or trauma. The child has no history of allergic rhinitis or upper respiratory infections. Denies taking any medication, either prescribed or over the counter. Based on this information the nurse would: A. maintain wait full management as most nose bleeds originate from anterior portion of nose. B. suggest that the patient use humidification to prevent dryness of nasal passages. C. consider referral to ENT for evaluation for other comorbidities. D. increase fluid content to maintain humidification as this may be due to environmental dryness.

C. consider referral to ENT for evaluation for other comorbidities. Even though the majority of nose bleeds are considered to be from the anterior portion of the nose, the fact that the patient has frequent nose bleeds without warning in the absence of irritation or disease states alerts the nurse that there may be other underlying comorbidities such as vascular disorders, leukemia, thrombocytopenia, and clotting factor deficiencies. As such the patient should be referred for further evaluation.

The goals of therapeutic management for congestive heart failure is to A. increase afterload and perfusion to tissues. B. decrease preload and increase afterload. C. decrease preload, afterload and increase contractility. D. decrease contractility and increase preload and afterload.

C. decrease preload, afterload and increase contractility. Treatment goals for congestive heart failure are aimed at decreasing preload (volume), afterload (resistance) and increasing contractility (improving efficiency).

Administration of colony stimulating agents for the pediatric oncology patient are based on the fact that A. increase the time frame for genetic adaptation. B. delays the onset of cellular regeneration. C. it will stimulate production of blood cell components. D. increase bone marrow recovery time.

C. it will stimulate production of blood cell components. Colony stimulating agents used in the treatment of pediatric oncology patients help to restore functional integrity of the bone marrow leading to decreased likelihood of infections. They decrease bone marrow recovery time and stimulate bone marrow growth of specific cellular components.

A child with sickle cell anemia develops severe chest pain, fever, a cough, and dyspnea. The nurse's first action is to A. administer 100% oxygen to relieve hypoxia. B. administer pain medication to relieve symptoms. C. notify practitioner because chest syndrome is suspected. D. notify practitioner because child may be having a stroke.

C. notify practitioner because chest syndrome is suspected. Severe chest pain, fever, a cough, and dyspnea are the signs and symptoms of chest syndrome. The nurse must notify the practitioner immediately. Breathing 100% oxygen to relieve hypoxia may be ordered by the practitioner, but the first action is notification because these symptoms indicate a medical emergency. Pain medications may be indicated, but evaluation is necessary first. Severe chest pain, fever, cough, and dyspnea are not signs of a stroke.

Nursing care of the infant and child with congestive heart failure includes A. force fluids appropriate to age. B. monitor respirations during active periods. C. organize activities to allow for uninterrupted sleep. D. give larger feedings less often to conserve energy.

C. organize activities to allow for uninterrupted sleep. The child needs to be well rested before feeding. The child's needs should be met to minimize crying. The nurse must organize care to decrease energy expenditure. The child in congestive heart failure has an excess of fluid, so forcing fluids is contraindicated. Monitoring of vital signs is appropriate, but minimizing energy expenditure is a priority. The child often cannot tolerate larger feedings; small, frequent feedings should be given to the child in congestive heart failure.

Nursing care of the child with myelosuppression from leukemia or chemotherapeutic agents should include to A. restrict oral fluids. B. institute strict isolation. C. use good hand washing technique. D. give immunizations appropriate for age.

C. use good hand washing technique. Good hand washing technique is the most effective means to prevent disease transmission in children with myelosuppression. There is no indication to reduce fluids in children with myelosuppression. Strict isolation is not necessary in children with myelosuppression. The child should not receive any live vaccines, because the immune system is not capable of responding appropriately to them.

Causes of anemia

Causes of Anemia 1. Poor production of RBC's... ORBody is just not producing RBC's fast enough... a sign of an underlying pathology (leukemia for example) caused by nutritional deficiency or bone marrow failure 2. Destruction of RBC's is greater than production of RBC's... Called Hemolytic AnemiaIt may result in jaundice... as bilirubin is the:Byproduct of the breakdown of RBC'sAs excess breakdown occurs, bili increasesIt has many possible causes, from mild to severe 3. Loss of RBC'sHemorrhage 4. Congenital syndromes

Treatment of brain tumors

Chemotherapy or radiation are used to help shrink the tumor size before surgery is preformed. Then the tumor is further reduced or removed with surgery. In some instances, the size of the tumor is decreased by a de-bulking surgery. Then chemotherapy or radiotherapy is used to finish eradicating the left over cells. It is not uncommon for children to have 2-3 forms of therapy.

Complications from sickle cell

Complications From Chronic Disease: } Cardiomegaly, murmur } Chronic lung disease } Renal failure } Retinal disease, even blindness } Skeletal deformities } Chronic leg ulcers } Hemiparesis, seizures

The nurse in planning care for the pediatric oncology patient anticipates implementing which action with regard to the administration of an antiemetic in a chemotherapy protocol? A. Providing the medication on a prn basis based on patient's presenting symptoms of nausea and/or vomiting. B. Administering the medication via the oral route following infusion of chemotherapy protocol. C. Providing medication with sips of water following clinical symptoms of nausea and/or vomiting. D. Administering 30 to 60 minutes prior to initiation of therapy.

D. Administering 30 to 60 minutes prior to initiation of therapy. Anticipatory management of an antiemetic is part of chemotherapy and/or radiation protocols. It is typically given 30 to 60 minutes prior to the infusion and administered in a scheduled sequence rather than based on a prn or when the patient presents symptomatically. Preferred route of administration is via parenteral route especially if the anticipated risk for nausea and/or vomiting is increased.

A diagnosis of rheumatic fever is being ruled out for a child. Which lab test(s) is/are the most reliable? Select all that apply. A. Throat culture C. C-reactive protein (CRP) D. Antistreptolysin-O titer (ASO) titer E. Elevated white blood count (WBC) F. Erythrocyte sedimentation rate (ESR)

D. Antistreptolysin-O titer (ASO) titer The most reliable and best standardized lab for antistreptococcal antibodies is an Antistreptolysin-O (ASO) titer. A throat culture indicates a current streptococcal infection. C-reactive protein (CRP) lab test indicates inflammation. An elevated white blood count (WBC) may indicate a possible infection but does not indicate a causative agent. An erythrocyte sedimentation rate (ESR) indicates inflammation.

What should the nurse recognize as an early clinical sign of compensated shock in a child? A. Confusion B. Sleepiness C. Hypotension D. Apprehensiveness

D. Apprehensiveness Apprehensiveness is indicative of compensated shock. Confusion is indicative of uncompensated shock. Sleepiness is not an indication of shock. Hypotension is a symptom of irreversible shock.

You are reviewing information relative to a patient's medical history for treatment of leukemia. Patient is exhibiting no clinical symptoms at this point in the treatment plan. In comparing bone marrow reports prior to and 6 months following chemotherapy, what information do you hope to obtain that would assist in evaluating the plan of care? A. Expectation that the results will be consistent indicating that goals have been met. B. Increased likelihood that atypical cells will be present suggesting a revision of the plan of care. C. Pancytopenic response indicating that chemotherapy treatment was successful. D. Determination of response to clinical therapy comparing pre and post procedure that will provide evidence to interpret whether medical treatment has been effective.

D. Determination of response to clinical therapy comparing pre and post procedure that will provide evidence to interpret whether medical treatment has been effective. Bone marrow biopsies are used both to diagnose as well as evaluate clinical response to chemotherapy (therapeutic management) used in the treatment of leukemia. While one would hope that the intervention was successful, until the results are compared and read by the pathologist, there is no way to state equivocally what the results will be at the histological level. Consistent findings pre and post treatment would indicate that treatment goals have not been met. Similarly, if clinical response is favorable, then one would not expect to see atypical cells. As the patient is not experiencing any symptoms, a diagnosis of pancytopenia would not be expected as this would indicate bone marrow failure.

You are working with the parents of a pediatric oncology patient who has successfully responded to therapy. The parents have questions regarding what to expect as the child continues to grow and develop throughout the life cycle. Which response would be appropriate with regard to the parent's concern? A. As the therapy has been successful, growth and development should proceed along a normal sequence. B. It may be a good idea to schedule your child for repeat imaging studies on a yearly basis so as to make sure that the child remains in remission. C. There may be anticipated growth and developmental delays associated with chemotherapy treatments but they are typically self-limiting in nature. D. Genetic counseling may be something to consider as the child reaches adulthood and is considering having children his/herself if the type of cancer that the child had was inherited.

D. Genetic counseling may be something to consider as the child reaches adulthood and is considering having children his/herself if the type of cancer that the child had was inherited. Even though medical treatment has been noted as being successful, continued observation and medical follow up is indicated. Growth and development should be monitored in accordance with recommended pediatric screening guidelines. Although imaging studies may be required at some point in time for follow up, yearly imaging studies may not be needed. Genetic counseling when the child reaches adulthood should be considered especially if the type of cancer was inherited. Growth and developmental delays are not considered to be normal and may not be self-limiting.

An adolescent is being treated for new-onset hypertension with medication. Firs line therapy previously tried was with dietary management but the decision has now been made to start oral medications. Which complaint if provided by the patient would indicate a potential concern? A. Patient states that he is no longer losing weight after being on the medication for one week's time. B. Patient states he is maintaining his oral intake of 8 glasses of water a day. C. He is taking the medication in the evening rather than taking the medication in the morning as prescribed as he thinks that he feels better and has less side effects. D. He reports that he occasionally feels "lightheaded" when getting out of a chair during the course of the school day in some of his classes.

D. He reports that he occasionally feels "lightheaded" when getting out of a chair during the course of the school day in some of his classes. Safety aspects should be considered with use of anti-hypertensives and the possibility of orthostatic hypotension. As such the patient should be assessed for this event and prospective safety management should be instituted. Anti-hypertensive therapy is typically not associated with weight loss. Maintaining fluid hydration and the fact that the medication dosing is taken in the evening rather than the daytime to minimize size effects is showing individualization to patient's needs.

Which findings are consistent with tumor lysis syndrome? A. Hypercalcemia and hyperkalemia B. Hypochloremia and hypokalemia C. Hyponatremia and hyperphosphatemia D. Hyperuricemia and hyperkalemia

D. Hyperuricemia and hyperkalemia The hallmark characteristics of tumor lysis syndrome are: hyperuricemia, hypocalcemia, hyperphosphatemia, and hyperkalemia.

A critical concept that needs to be maintained during intravenous administration of chemotherapy for a pediatric patient is? A. Positioning the patient in a semi-fowler's position. B. Not use an infusion device but rather allow for a free-flow line. C. Continue the infusion regardless if the patient develops a rash. D. Maintaining the integrity of the parenteral access line.

D. Maintaining the integrity of the parenteral access line. Administration of chemotherapy via parenteral access requires that the integrity of the access line be maintained and monitored by the nurse. If there is any indication that the site as infiltrated, then the infusion must be immediately stopped. Patient positioning is variable depending on patient comfort. An infusion device must be used as this is considered to be a titratable infusion. If the patient develops a rash in response to chemotherapy, this may be an indication of a hypersensitivity reaction. Intervention is required with notification of health care provider and discontinuing the infusion.

A pediatric oncology patient has developed a nose bleed. Which testing parameter would be indicted in order to decide if medical treatment is needed? A. Chest x-ray B. CT of the nose C. Lumbar puncture D. Platelet count

D. Platelet count Pediatric oncology patients are at an increased risk for hemorrhage and bleeding. Evidence of a nose bleed may indicate thrombocytopenia and as such a platelet count should be obtained. Imaging studies such as CT and chest x-ray will not provide information related to hemostasis. An invasive procedure such as a lumbar puncture would be indicated if there was possibility of an infectious process.

The nurse is assessing a pediatric oncology patient's nutritional status. Which diagnostic tests would provide best practice approach? A. Albumin, blood urea nitrogen (BUN) and daily weight B. Skinfold assessments and daily weight C. Intake and output with daily calorie count D. Serum prealbumin, albumin and transferrin

D. Serum prealbumin, albumin and transferrin No one diagnostic test or measurement provides enough evidence to evaluate the nutritional well-being of an individual patient. BUN provides evidence of hydration status but typically should be viewed using a BUN creatinine ratio to provide detailed information about a patient's renal status. Skinfold assessments while important again do not provide enough evidence even with the addition of a daily weight to evaluate one's nutritional status. Intake and output measurements in combination with daily calorie count are representative of hydration and nutritional support but do not provide information relative to nutritional body stores.

The nurse suspects a child is having an adverse reaction to a blood transfusion. What should the nurse's first action be? A. Notify the physician. B. Take vital signs and blood pressure and compare them with baseline values. C. Dilute infusing blood with equal amounts of normal saline. D. Stop the transfusion and maintain a patent intravenous line with normal saline and new tubing.

D. Stop the transfusion and maintain a patent intravenous line with normal saline and new tubing. The priority nursing action is to stop the transfusion and maintain a patent intravenous line with normal saline and new tubing. If an adverse reaction is occurring, it is essential to minimize the amount of blood that is infused into the child. The physician should be notified after the blood transfusion is stopped and normal saline is infusing. Vital signs should be assessed after the blood transfusion is stopped and normal saline is infusing. Blood should not be diluted; it should be returned to the blood bank if an adverse reaction has occurred.

A child is coming to the clinic with his parents for a sports physical. Upon reviewing the patient's history, there is a notation that the child has been recently treated six months ago for immune thrombocytopenia purpura (ITP). Based on this notation, the nurse would provide this recommendation? A. The child should not play any sports or participate in any physical activity while in school. B. The child should take art classes rather than participate in sporting events. C. The child will have to repeat blood work before any determination can be made. D. The child can play non-contact sports but will have to be monitored if any bruising or bleeding should occur.

D. The child can play non-contact sports but will have to be monitored if any bruising or bleeding should occur. Contact sports should be avoided in a patient who has had prior treatment for ITP. The nature of ITP being idiopathic, it is important to protect the patient from impending trauma related to contact. However, the child as part of normal growth and development should be able to engage in non-contact sports activities. Being that the treatment was recent and that ITP is idiopathic, prospective management and monitoring should be included in the plan of care at this time.

What should nurses stress when counseling parents regarding the home care of the child with a cardiac defect before corrective surgery? a. The importance of reducing caloric intake to decrease cardiac demands b. The importance of relaxing discipline and limit setting to prevent crying c. The need to be extremely concerned about cyanotic spells d. The desirability of promoting normalcy within the limits of the child's condition

D. The desirability of promoting normalcy within the limits of the child's conditionThe child needs to have social interactions, discipline, and appropriate limit setting. Parents need to be encouraged to promote as normal a life as possible for their child. The child needs increased caloric intake after cardiac surgery. The child needs discipline and appropriate limit setting, as would be done with any other child his or her age. Because cyanotic spells will occur in children with some defects, the parents need to be taught how to assess for and manage them appropriately, thereby decreasing their anxiety and concern.

The parent of a child receiving an iron preparation tells the nurse that the child's stools are a tarry black color. The nurse should explain that this is A. a symptom of iron-deficiency anemia. B. an adverse effect of the iron preparation. C. an indicator of an iron preparation overdose. D. a normally expected change due to the iron preparation.

D. a normally expected change due to the iron preparation. An adequate dosage of iron turns the stools a tarry black color. This is considered a normal abnormal effect related to iron medication. Tarry black stools are not a sign of iron-deficiency anemia nor are they an indicator of iron preparation overdose.

Therapeutic management of the patient with systemic lupus erythematosus (SLE) includes A. application of cold salts to suppress the inflammatory process. B. a high-protein, low-salt diet. C. a rigorous exercise regimen to build up muscle strength and endurance. D. administration of corticosteroids to control inflammation.

D. administration of corticosteroids to control inflammation. Corticosteroid administration is the primary mode of therapy currently for SLE. The application of cold salts will not affect the inflammatory process associated with SLE. A balanced diet without exceeding caloric expenditures is recommended. Exercise should be done in moderation.

The nurse is explaining blood components to an 8-year-old child. Based on the nurse's knowledge of child development, the most appropriate description of platelets is that they A. help keep germs from causing infection. B. make up the liquid portion of blood. C. carry the oxygen you breathe from your lungs to all parts of your body. D. help your body stop bleeding by forming a clot (scab) over the hurt area.

D. help your body stop bleeding by forming a clot (scab) over the hurt area. Platelets are involved in homeostasis. White blood cells help protect the body from infection. The liquid portion of blood id known as plasma. Red blood cells are involved in oxygenation of tissues in the body.

The best approach that would facilitate improved outcomes when using surgical treatment for operable cancers is A. when there is evidence of adjacent tissue involvement. B. performing amputation rather than attempting resection. C. using multiple excisions to remove the tumor. D. if the tumor is encapsulated and localized.

D. if the tumor is encapsulated and localized. Tumors that are localized and encapsulated represent the best approach for improved outcomes for the surgical cancer patient as this indicates that the tumor is not showing evidence of metastasis. Evidence of adjacent tissue involvement means that the tumor has already metastasized. Resection of bone rather than amputation is associated with improved outcomes. Minimal incision surgical approach is favored to improve functioning and help maintain cosmesis.

Surgical repair for patent ductus arteriosus (PDA) is done to prevent the complication of a. pulmonary infection. b. right-to-left shunt of blood. c. decreased workload on left side of heart. d. increased pulmonary vascular congestion.

D. increased pulmonary vascular congestion. A PDA allows blood to flow from the aorta (high pressure) to the pulmonary artery (low pressure). If the PDA stays open, increased pulmonary vascular congestion can occur. The increased pulmonary vascular congestion is the primary complication; pulmonary infection may occur, but it is not the priority complication. A PDA involves a left-to-right shunt of blood. The decreased workload on the left side of the heart is not a priority complication of a PDA.

Congenital heart defects have traditionally been divided into acyanotic or cyanotic defects. Based on the nurse's knowledge of congenital heart defects, this system in clinical practice is A. helpful, because it explains the hemodynamics involved. B. helpful, because children with cyanotic defects are easily identified. C. problematic, because cyanosis is rarely present in children. D. problematic, because children with acyanotic heart defects may develop cyanosis.

D. problematic, because children with acyanotic heart defects may develop cyanosis. This classification is problematic. Children with traditionally named acyanotic defects may become cyanotic, and children with traditionally classified cyanotic defects may be pink at times. The classification does not reflect the blood flow within the heart. Cardiac defects are best described by using the actual pathophysiologic process and mechanism. Children with cyanosis may be easily identified, but that does not help with the diagnosis. Cyanosis is present when children have defects where there is mixing of oxygenated blood with unoxygenated blood.

A child with β-thalassemia is receiving numerous blood transfusions. In addition, the child is receiving deferoxamine (Desferal) therapy. The child's parents ask the nurse what deferoxamine does. The most appropriate response by the nurse is A. the medication helps to prevent blood transfusion reactions. B. the medication stimulates red blood cell production. C. the medication provides vitamin supplementation. D. the medication helps to prevent iron overload.

D. the medication helps to prevent iron overload. A side effect of hypertransfusion therapy is often iron overload. Deferoxamine is an iron-chelating drug that binds excess iron; therefore, it can be excreted by the kidneys. It does not prevent blood transfusions nor stimulate red bell production. It is not a vitamin supplement.

A young child with tetralogy of Fallot may assume a posturing position as a compensatory mechanism. The position automatically assumed by the child is a. the low Fowler position. b. the prone position. c. the supine position. d. the squatting position.

D. the squatting position.The squatting or knee-chest position increases the return of blood flow to the heart for oxygenation in a child with a defect that consists of decreased pulmonary blood flow. The low Fowler, prone or supine position does not offer any physiologic advantage to the child related to cardiac compensation.

The primary therapy for secondary hypertension in children is a. weight reduction. b. low-salt diet. c. increased exercise and fitness. d. treatment of underlying cause.

D. treatment of underlying cause. Secondary hypertension is a result of an underlying disease process or structural abnormality. It is usually necessary to treat the problem before the hypertension will be resolved. Weight reduction and a low-salt diet are usually effective in managing essential hypertension. Increased exercise and fitness are usually effective in managing essential hypertension.

What diagnostics are necessary for leukemia?

For either type of leukemia, these tests are performed. CBC to look at the cells, maturity, and numbers. Typically there will be those increased numbers of blasts cells (immature white cells), low red cells and low platelets. Bone marrow aspiration is preformed to determine function of marrow to produce cells. Chest X-Rays to determine lung status and involvement of mediastinum. Lumbar puncture, the provider is looking for cancer cells in the cerebral spinal fluid. This checks for metastasis to the central nervous system (CNS).

Brain tumor s/s

It does not matter what type of tumor (astrocytoma, Medulloblastoma, or Ependymoma), it is the location and size that causes the related problems. All tumors cause increased intracranial pressure. The tumor is taking space that was occupied by another structure. The brain becomes 'overfilled' so pressure increases. Glasgow coma scale evaluations will show lower scores. Sometimes personality changes occur. Parents usually report this as the child being more grumpy or irritable than usual.

Two types of leukemias

Leukemia is classified by the types of cells that are affected. ALL - or acute lymphoid leukemia is a problem with the lymphocytes. ALL affects 2-5 year olds AML - or acute Myelogenous leukemia is a problem with the granular leukocyte, monocyte, and platelet production. AML affects 15-19 year olds

Neuroblastoma

Neuroblastoma - 2nd most common solid tumor of childhood. Most common malignant extra-cranial solid tumor in kids. Although this sounds like it should be about tumors in the brain, it is not. Neuroblastoma is the 2nd most common solid tumor in children. Proliferation of "neural crest cells" during embryonic development - As these cells proliferate, they begin to form a solid mass or tumor - Tumor then infiltrates into adjacent normal tissue & organs. Neuroblastoma is a cancer that arises from the neural crest cells during fetal development. - Neuroblastoma is another one of the cancers that is "staged" This is the INNSS for this cancer. Typically the higher the number, the more advanced the cancer. This also demonstrates some of the sites of origin and metastasis. - Depends on extent of disease & location of tumor - Most present with primary abdominal mass with a protuberant, firm abdomen - Can also arise in the renal system, eyes, lymph nodes (especially cervical and supraclavicular), skeleton, spinal cord, cranium, & adrenal gland - The primary site of this cancer can be located in any number of areas. Most commonly it arises in the abdomen. Much like brain tumors, location is going to determine symptoms. - Impaired mobility (even paralysis) if spinal cord compressed - Urinary frequency or retention if renal system - Periorbital edema if ocular involvement - Bone pain if skeleton is involved - HTN, flushing, tachycardia, diaphoresis if adrenal glands involved - With widespread metastasis.. pallor, weakness, irritability, anorexia, wt. loss

Leukemia labs

On the lab reports of a child with leukemia, you would typically see low counts with a high number of blast cells. What are blasts? Blasts are immature white cells. So there are lots of baby white cells in the blood stream. This is actually an over-production of leukocytes - but they are immature and ineffective at their job.

Wilm's Tumor (Nephroblastoma)

Wilm's tumor: Nephroblastoma - a tumor located on top of the kidney ('Nephro'- should have given that away). This tumor does not typically invade the kidney. It is encapsulated (contained in a sac). The tumor does not cross the midline. Palpating this tumor could rupture the sac and allow cells to escape and cross to adjacent tissues. If palpation must be preformed, it should be done very gently. ~6% of childhood cancers • Rapidly growing tumor • Most common malignant renal and intra-abdominal tumor of childhood • Encapsulated tumor • IMPORTANT: Do not palpate tumor unless absolutely necessary... may cause dissemination of cancer cells to adjacent tissue This type of cancer most commonly affects young boys. This one does have a genetic predisposition. Often when Wilm's is diagnosed, the family will report that dad or grandfather had the same thing when they were young boys. This type of cancer is sometimes associated with other malformations or defects. When it is diagnosed, if the child has not been previously found to have urinary malformations, cardiac anomalies, or neurofibromatosis, tests may be preformed to rule these out. Because this tumor compresses the kidney, renin production is disrupted and the result is hypertension. Sometimes this is the 'alert' to discovering the tumor. The other symptoms go with the fact that the tumor is disrupting the proper function of the kidney. This cancer is usually unilateral or just on one side. • Abdominal mass...Not crossing midline • Compresses kidney -> renin à HTN • Microscopic RBCs in the urine • Fatigue, anemia, fever

The nurse should explain to the parents that their child is receiving furosemide (Lasix) for severe congestive heart failure because of its effects as a. a diuretic b. a beta-blocker c. a form of digitalis d. an ACE inhhibitor

a diuretic Furosemide is a loop diuretic used to eliminate excess water and salt to prevent the accumulation of fluid associated with congestive heart failure.

Leukemia signs and symptoms

affects 2-5 year olds, The over-production of white cells creates other problems. With this over production, the other blood cells decrease in numbers due to the competition for the nutrients needed for production. Now, think about the problems the patient would have and the things that would be seen if all the blood cells were all affected in a bad way. Low red cells are going to lead to anemia. With anemia, think of all the other aspects that are affected - oxygen carrying capacity is decreased leading to hypoxia. With hypoxia the child would be tired, fatigue easily, and look pale. Platelets are affected, so bleeding times would be increased and there would be decreased clotting capacity. Bleeding gums, easy bruising, and having blood in stools with straining are some of the side effects of low platelets. With very few mature white cells, the patient risk for infection increases.

Sickle cell anemia and sickle cell disease

} A genetic disorder found primarily in African Americans & Hispanics which results in: ◦ Obstruction caused by the "sickled" RBC's ◦ Increased RBC destruction } Sickle Cell Trait: ◦ Child receives the positive sickle cell gene from one parent and becomes a carrier, but will not have symptoms ◦ Sickle Cell Disease (Sickle Cell Anemia): ◦ Child receives a positive sickle cell gene from both parents. Will be symptomatic. Diagnosing sickle cell } Symptoms vary in severity & frequency. } No sxs until 4-6 mo. of age } Diagnosis: Hgb Electrophoresis What happens in sickle cell? } RBC's cycle in and out of "sickling" episodes } Causes vaso-occlusion and pain from ischemia } Causes damage to tissue receiving decreased blood supply Clinical manifestations of sickle cell disease } The effects of sickling & infarction on organ structures occurs in the following sequence: ◦ Stasis with enlargement ◦ Infarction with ischemia & destruction ◦ Replacement with fibrous tissue (scarring) ◦ Organs most seriously affected over time: lungs, spleen, brain } Chronic anemia (Hgb 6-9)

Sickle cell nursing education

} Teach parents to TRY to prevent sickling episodes: ◦ Avoid extreme cold ◦ Promote hydration to prevent sickling ◦ Prevent infections by promoting immunizations

Cooley anemia nursing care

} Teach parents/family why frequent transfusions & chelation therapy are important } Help the child & family to adjust to chronic disease } Observe for complications from multiple blood transfusions OR disease process } Promote genetic counseling & testing of other family members for presence of thalassemia trait

aplastic anemia

} What Is It? ◦ Bone marrow ceases RBC production ◦ Characterized by profound depression of RBC's , but normal or slightly decreased WBC & Platelets } Types: ◦ Fanconi Syndrome: } Primary: present @ birth as a congenital issue ◦ Acquired } Causes of acquired aplastic anemia: ◦ More than 70% idiopathic ◦ Drugs } Antineoplastic } Antibiotics: chloramphenicol and sulfonamides } Anticonvulsants ◦ Toxins ◦ Infections ◦ Malnutrition } Diagnosis: Bone marrow aspiration biopsy } Treatment involves 2 approaches: ◦ Restore function to the marrow ◦ Replace bone marrow through transplantation (best option when donor available) } Medications Post Transplant: All suppress immune system to avoid rejection of BM transplant

Thalassemia anemias

§ The "thalassemias": a group of genetic blood disorders caused by increased RBC destruction & poor Hgb prod. § The most common type of thalassemia is Beta Thalassemia Anemia • Classified as major or minor

Nursing care of child pediatric oncology

• Assess oral mucosa daily • Offer oral hygiene after meals/snacks • Use SOFT toothbrush and mild toothpaste • Rinse mouth frequently • Hard candy to suck on • Medicated mouth rinse to reduce pain (dr. order) • Bland foods/fluids • Avoid extremely hot and cold foods/beverages • Restrict contact with infected healthcare workers, family and friends • Use good personal hygiene... keep nails short and clean • Remove sources of infectious organisms: fresh flowers & veg's. • Hand washing!!!! • Low blood counts increase the risk of infection. Protecting the patient from others who might be sick is critical. Good handwashing by staff caring for the child is essential. Decreasing the number of people who enter the child's room in necessary. Anything that can be done to decrease exposure should be done.

Ependymoma

• Even though 3rd on the list of childhood brain cancers, they are actually rare • Occur more often in children < 3 yrs., but are most often diagnosed @ 4-6 yrs. • Arise within the cells within the ventricles • Although Ependymoma are rare, due to their place of origin, they quickly and readily metastasize to the CNS and then have overall invasion. They actually originate in the ventricles.

maintenance

• Goal: Prevention of relapse - Started once remission is achieved - Use of oral chemotherapy - Usually lasts 2-3 years. • Boys may remain on maintenance therapy longer due to possibility of testicular involvement (with leukemia) • Maintenance is a longer period of time, but the treatments are not as harsh or frequent. Blood counts are still monitored during this time and sometimes spinal taps continue to be performed.

Intensification therapy

• Goal: to eradicate any residual cancer cells • Time of most intense meds!!! - HIGH doses of chemotherapy • Usually lasts about 6 months • The intensification therapy period is also known as consolidation. Children may receive chemotherapy every 3 weeks during this time. They just start to rebound with blood counts and start to feel better and its time for another treatment. It is a short period of time in the grand scheme of cancer treatment therapy. The child may be receiving more than one chemotherapy drug during this time. Usually the drugs are IV, some are oral. Some children, depending on the type of cancer they have, will receive IM injections.

Induction

• Goal: to induce remission • Defined as absence of all signs of cancer (< 5% blasts in bone marrow) • Eradicates lymphocytes • Places child @ high risk for infection & hemorrhage following this phase - Lasts 4-6 wks.

Reinduction

• Goal: to place the child back into remission • Combinations of chemotherapy used • Probability of relapse occurring decreases over time • Re-induction happens if the child relapses or has the reappearance of cancer. The goal is to get those new cells eradicated as soon as possible and get the child back into remission.

CNS Prophhylaxis

• Goal: to prevent CNS involvement • These are the intrathecal injections. Spinal taps are performed and medication is injected.

Medulloblastoma

• Highly malignant brain cancer • Originates in the cerebellum or posterior fossa • Spreads through the CSF... which makes it different from other brain tumors - Metastasizes to other parts of brain/spinal cord • Medulloblastoma is highly malignant. It typically invades the cerebellum and because of that location, can easily invade the 4th ventricle. This enhances CNS invasion.

4 stages of chemotherapy

• Induction • CNS Prophylactic Therapy (Sanctuary) • Intensification Therapy (Consolidation) • Maintenance Therapy • When patients are started on chemotherapy, baseline labs, X-rays, ECHOs, etc., are performed depending on the drugs to be used. The first part of chemo administration is called induction. Then there is prophylaxis of the cerebral spine fluid. Spinal taps are usually performed to test for cancer cells, and then chemo drugs are injected into the spinal fluid (an intrathecal injection). This may be repeated during the course of the therapy. The really intensive therapy happens next. Most patient now receive their chemotherapy and radiotherapy treatments in the outpatient setting. After intensive therapy, patients are on a maintenance therapy plan for a longer period of time.

Rhabdomyosarcoma

• Malignancy of muscle • Peak incidence 2-6 years & 15-19 years • About 3% of childhood cancer falls into this category • Most common site is head & neck - Periorbital presentation is common • Other sites: - GU area, trunk, and extremities • The 'myo' part of this cancer name helps identify it as a cancer of the muscle. This one has a gap in incidence age. Little ones and then older teens. It can be in any muscle, but most commonly is found in the neck and head. • Soft to hard non-tender mass • May cause pain • Swollen area • If in head - Often not found until eye begins to bulge forward • If found in neck, child may hold head to one side • Symptoms are determined somewhat by location of the tumor and size of the tumor when compared to size of the child. It can change the physical appearance of the child. Some younger children with neck tumors will start having trouble turning their head toward the affected side. Parents may notice the neck looking larger or fuller on the tumor side. Some rhabdomyosarcomas that form in the head may not be noticed until the eye starts to bulge outward. • The same types of treatment are used for rhabdomyosarcomas as some of the other tumors. Chemotherapy to help shrink the tumor, surgery to remove the tumor, then radiotherapy after to catch any residual cells. Sometimes the order is changed depending on the size and location of the tumor. It is not uncommon to have all three forms of therapy.

Nursing considerations for brain tumor surgery

• Monitor & manage ICP!!! • Wound care post op • Administer chemotherapy • Manage radiation related side effects • Protect from infection with bone marrow suppression secondary to chemotherapy & radiation • Nutritional support There are many things common with any kind of brain surgery. ICP must be monitored and a normal level maintained. Administering any other medications as ordered. Sometimes chemo is not started for a week to 10 days. This is to allow healing of the skin and tissue to begin. Remember chemotherapeutic drugs destroys all fast growing cells, that includes the skin and other tissues that need to heal after surgery. Radiotherapy care is also important. In the peds textbook, there is a table with side effects and treatment with radiotherapy (Table 25-1). Good nutrition is important during this time also. But remember, depending on the cognitive level of the child, eating can be an challenge. Think about the nutrients needed and how they can be persuaded to eat them. If a child likes peanut butter - so give them the jar and a spoon if that is how they prefer it. Smoothies, protein shakes, snacks, small frequent meals...whatever it takes to get them to consume some high protein, nutritious meals. Maybe they need a temporary gastrostomy tube for feedings to get those extra calories. TPN (total parenteral nutrition) is a last resort, even if it is just temporary.

Complications of brain surgery

• Neurological damage • Developmental delay • Behavioral changes • Increased ICP • Seizures • Coma • As with any brain surgery, there can be sequelea. There can be neurological damage from the surgery itself or from the tumor. Depending on the location, there can be some behavioral (personality) changes. Developmental delays can occur. Swelling can result causing increase intracranial pressures. This can lead to seizures. Uncontrolled or severe enough and these factors can lead to the dead of the child. • Death

Frequent transfusion complications

◦ Fe Overload: Can lead to hepatic fibrosis if left unchecked. So... what do you do? ◦ Chelation: Removing Excess FE Achieved with Desferal IV or IM. (generic: deferoxamine) Promotes iron excretion. Fun for kids, huh???