Module 4 Hematologic/Oncologic 6-8 Questions on Final From this Module
Priority study questions
How do pediatric cancers differ from adult cancers?
How do you minimize the risk for infection for a child with compromised immune function?
General study priorities
Absolute neutrophil count (ANC) and calculation
The following formula calculates the ANC:
(% bands + % segmented cells) × total WBC count = ANC
Example: (3% bands + 50% segmented cells) × 1,500 = 795
When the ANC is less than 500, the client is at high risk for infection.
Diagnostic testing: lumbar puncture
Laboratory testing: CBC (especially platelets, hemoglobin, WBC, ANC), CRP, blood cultures
Recognizing and managing: anemia, thrombocytopenia, and neutropenia
Managing side effects of chemotherapy—immunosuppression, anemia, thrombocytopenia, nausea/vomiting
Neutropenic precautions: when to initiate, guidelines/restrictions
Myelosuppression- what is this? What causes it? What are symptoms?
Disorders
For each disorder, study pathophysiology, assessment, and nursing care (including caregiver education). Select study priorities are listed-these are not a comprehensive list of study topics.
Iron Deficiency Anemia
Pathophysiology
The most common type of anemia occurs when there are not enough healthy RBCs to carry oxygen to the body’s tissue. This is a dietary deficiency that is more common among infants who are given cow’s milk.
Assessment
Risk factors
Premature birth resulting in decreased iron stores
Excessive intake of cows milk in toddlers
Milk is not a good source of iron
Milk takes place of iron-rich solid foods
Malabsorption disorders
Infants: Gerd, Pyloric stenosis
Older child: GI Polyps, Colitis
Expected findings
Tachycardia, pallor, brittle spoon-shaped fingernails, fatigue, irritability, muscle weakness, systolic heart murmur, cravings for non-nutritive substances (ice, dirt, paper)
Lab Tests
Decreased RBC, Hgb, Hct
Treatment: FERROUS SULFATE
Administration considerations:
Timing: Administer 1 hour before or 2 hours after dairy, antacids, or calcium to maximize absorption.
Fasting: Offer on an empty stomach for better absorption; may be taken with a small amount of water.
Gastrointestinal Effects: Common side effects include nausea, diarrhea, and constipation; monitor patients and educate caregivers.
Vitamin C Co-Administration: Taking with vitamin C can improve absorption.
Dental Considerations: Use a straw for liquid forms to prevent tooth staining and encourage oral hygiene.
Monitoring: Check hemoglobin and ferritin levels regularly, and inform caregivers of iron overload signs, such as abdominal pain.
Patient Education: Emphasize adherence to the dosing schedule to optimize treatment outcomes and prevent complications.
Developmental considerations
Dietary considerations-sources, impact of too much cow’s milk
Sickle Cell Disease - group of diseases in which abnormal sickle hemoglobin S (HbS) replaces normal adult hemoglobin (Hgb A)
Pathophysiology
Partial or complete replacement of abnormal hemoglobin S for normal hemoglobin A. The deformed RBC changes from a round to sickle (crescent) shape.
Assessment
Risk factors
SCD is an autosomal recessive genetic disorder
SCA primarily affects African Americans. Other forms of SCD can affect individuals of Mediterranean, Indian or Middle Eastern descent.
Children who have the sickle cell trait do not manifest the disease but can pass the trait to their offspring.
Expected Findings
Family history of sickle cell anemia or sickle cell trait
Reports of pain, shortness of breath, fatigue, pallor, pale mucous membranes, jaundice, hands and feet cool to touch, dizziness, headache
Nursing care (including caregiver education)
Promote rest to decrease oxygen consumption
Administer oxygen as prescribed
Provide intense hydration therapy while maintaining fluid and electrolyte balance
Monitor I&O
Give oral fluids
Use caution with potassium replacement
Administer blood products, usually packed RBCs, and exchange transfusions per facility policy. Observe manifestations of hypervolemia and transfusion reaction.
Treat and prevent infection
Administer antibiotics
Perform frequent hand hygiene
Give oral prophylactic penicillin
Administer pneumococcal conjugate vaccine, meningococcal vaccine, and Haemophilus influenzae type B vaccine.
May need prophylactic penicillin before dental procedures
Seek medical care with temp of 38c or 100.4F
Dactylitis (hand-foot syndrome) is a common manifestation in sickle cell disease, characterized by painful swelling of the fingers or toes due to vaso-occlusive crises.
Severe swelling and inflammation of an entire finger or toe, creating a “sausage digit” or “sausage finger” appearance.
Crisis management/treatment of a vasoocclusive crisis
YES
Analgesics for pain
Ibuprofen: Nonsteroidal anti-inflammatory drug (NSAID) that helps reduce pain and inflammation. Use with caution in children with renal impairment.
Morphine sulfate: Opioid analgesic effective for moderate to severe pain management. Monitor for respiratory depression, especially in patients with existing respiratory issues.
Oxycodone: Opioid pain reliever, often used in combination with acetaminophen for more effective pain control. Ensure close monitoring for signs of misuse or dependence.
Hydromorphone: More potent than morphine, used for severe pain in emergencies. Dosage must be carefully managed due to the risk of overdose.
Methadone: Used for pain management and as part of a detox program for those with opioid dependency. Requires careful dosing and monitoring.
Oxygen therapy: Administer supplemental oxygen if the patient shows signs of hypoxia (low blood oxygen). This helps alleviate pain by improving oxygen delivery to tissues.
Warm compresses: Apply to affected areas to improve blood flow, alleviate discomfort, and relax muscles. Direct warmth can provide immediate relief and promote comfort.
Rest: Encourage periods of rest to combat fatigue and minimize oxygen demand. Activity/rest cycling can help balance exertion and recovery.
Hydration: Adequate fluid intake is critical, especially intravenous hydration if oral intake is insufficient. Proper hydration helps to decrease blood viscosity, thereby reducing the risk of vascular occlusion.
Medications: Maintain a consistent medication schedule for effective pain management;
Hydroxyurea (antineoplastic agent): Used to reduce the frequency of painful crises and potentially lower the need for blood transfusions. It acts by increasing fetal hemoglobin (HbF) levels, reducing sickling and improving blood flow.
DO NO DO DURING VASOOCLUSIVE CRISIS
Cold compresses: Avoid use, as cold can lead to vasoconstriction and worsening of pain by impeding blood flow.
Avoid dehydration: Monitoring fluid intake is essential, as dehydration can exacerbate vaso-occlusive events.
Delay pain medications: Prompt administration of analgesics is crucial; delaying pain relief can result in unnecessary suffering and complications.
Safety measures in chemotherapy include:
PPE: Use gloves, gowns, masks, and eye protection to minimize exposure.
Hand Hygiene: Perform hand hygiene before and after patient contact and medication handling.
Double Checking Dosages: Confirm dosages with another licensed professional.
Central Line Care: Manage central lines carefully to prevent infections with regular dressing changes and caregiver education.
Common side effects of chemotherapy are significant immunosuppression:
Anemia: Monitor hemoglobin and hematocrit due to marrow suppression.
Thrombocytopenia: Watch for bleeding signs, such as bruising or petechiae.
Nausea and Vomiting (N/V): Administer antiemetics proactively.
Managing side effects involves monitoring for infections and educating patients about avoiding exposure to sicknesses. Encourage hand hygiene, monitor for unusual bleeding, and provide gentle handling to prevent stress. To alleviate N/V, maintain a well-ventilated area, suggest bland foods and small meals, and provide antiemetics before symptoms occur.
Personal Protective Equipment (PPE): Always use gloves, gowns, masks, and eye protection when handling chemotherapy agents to minimize exposure risks.
Hand Hygiene (HH): Perform meticulous hand hygiene before and after patient contact or handling medications to prevent the transmission of infections.
Double Checking Dosages: Confirm the dosage and administration route with another licensed professional to prevent errors.
Central Line Care: Careful management of central line sites to prevent infections, including regular dressing changes and educating the patient and caregivers on care techniques.
Common side effects associated with chemotherapy include significant immunosuppression, which may lead to:
Anemia: Resulting from marrow suppression, leading to fatigue and weakness. Regular blood tests to monitor hemoglobin and hematocrit are essential.
Thrombocytopenia: Lowered platelet counts increase the risk of bleeding. Monitor for signs such as petechiae, bruising, or bleeding gums.
Nausea and Vomiting (N/V): A highly common issue, often leading to discomfort and distress. Administer antiemetics proactively and evaluate their effectiveness.
Leukemia (acute lymphocytic/ ALL)
Pathophysiology
White blood cell (WBC) overproduction occurs, although the count is actually low. Immature cells do not deliberately attack and destroy normal cells but compete for metabolic elements.
Possible cause of ALL: Chromosome problems, radiation, previous chemotherapy
Symptoms: Bone and joint pain, bruising, bleeding, fatigue, swollen glands, weight loss
Assessment
Cough, wheezing, tracheal/bronchial compression and respiratory distress/arrest related to mediastinal mass and compression of great vessels
Liver and enlarged spleen with pain, GI symptoms, urinary symptoms
Enlarged lymph nodes greater than 1 cm and firm but not painful in regional areas, elbow and supraclavicular nodes
Nursing care (including caregiver education)
Blood transfusion
Chemotherapy to suppress production of abnormal cells
Effects of bone marrow suppression: anemia, thrombocytopenia, neutropenia
Anemia with weakness, fatigue, pallor, dyspnea, cardiac dilation, and anorexia
Thrombocytopenia (low platelet count) with bruises, petechiae, purpura, large ecchymosis, epistaxis, gums and sclera hemorrhages
Neutropenia with infection of skin and lungs, fever, decreased wound healing
Safety considerations (risk for bleeding, risk for infection, etc)
Prevent bleeding from the mouth with a soft toothbrush, offer mouth care, and provide a safe environment.
Prevention of infection: hand hygiene, reduction of environmental molds and organisms from plants and fresh fruits.
Brain Tumor - classified into supratentorial and infratentorial tumors. Etiology may be genetic or environmental in terms of tumor origin
Pathophysiology
A common Perinatal posterior fossa tumor is medulloblastoma that originates in the cerebellum. Tumor cells may spread through the spinal fluid to the spinal cord, and obstructive hydrocephalus may occur.
Glioma is a broad term for any cancer that develops from the glial cells. Glial cells hold the nerve cells in place and protect from infection.
Astrocytoma is the most common type of glioma diagnosis in children. It can form in the brain, brainstem and spinal cord.
Tumors start in star-shaped brain cells called astrocytes.
Assessment
Increased head size in infants is a sign of increased ICP, frequently a complication from the presence of brain tumor
Headache on awakening
Monitor pulse pressure (difference between systolic and diastolic pressure)
Pupils sluggish, dilated, or unequal and weak hand grasp
Nursing care (including caregiver education)
Assess postsurgical wound, including estimate of dressing drainage
Assess mouth for soreness and open areas of stomatitis
Monitor for seizures and changes in posturing
Monitor movement of all extremities, gag reflex, and blink or swallowing reflex
Elevate HOB 30 degrees in supratentorial craniotomy; avoid Trendelenburg’s position because of increases in ICP
Align the body will pillows so neck and heads are midline
With infratentorial craniotomy, give fluids after return of gag and swallowing reflex
Signs of increased intracranial pressure
Nausea and vomiting
Monitor IV fluid to prevent cerebral edema, increased ICP and hydrocephalus
Post-operative care
Neuroblastoma - malignancy that occurs in the adrenal glands, sympathetic chain of the retroperitoneal area, head, neck, pelvis or chest.
Pathophysiology
Neuroblastoma is a malignancy that occurs in the adrenal glands, sympathetic chain of the retroperitoneal area, head, neck, pelvis, or chest. It originates from primitive nerve cells and often remains “silent” until advanced stages.
Assessment
Manifestations depend upon the location and stage of condition
Palpable abdominal mass
Weight loss, constipation, anorexia
Diaphoresis, hypertension
Manifestations of metastasis include jaundice, dark pigmented nodules on the extremities, dyspnea, edema of face and neck
Nursing care (including caregiver education)
Skeletal survey
Skull, neck, chest, abdominal, and bone CT scans
Monitor for findings of infection
Keep the child’s skin clean and dry
Assess the mouth for mucosal ulcerations
Originates from primitive nerve cells
Often “silent”
Wilms’ Tumor - is a malignancy that occurs in the kidneys or abdomen. The tumor is usually unilateral, with 10% of cases affecting both kidneys.
Pathophysiology
Originates in fetal development, with a tumor typically found on the child’s kidneys at age 3 or 4 years. Patients usually report finding a bump around the waistband or diaper area of the child, often during bath time. Wilms’ tumor may affect one or both kidneys
Assessment
Lump is evident in the abdomen/waistband area
May have pain in the area associated with the lump
May have increased blood pressure because of changes in the renin-angiotensin system
May have a fever for no identified reason
Nursing care (including caregiver education)
DO NOT PALPATE TUMOR SITE because it can cause METASTASIS
Ensure that blood pressure is obtained as ordered; manual pressures are indicated with the changes in the renin-angiotensin system.
Child should wear clothing that is loose around the waistband
Avoid pushing or lifting in tumor area when handling and bathing the child
Surgery will be needed to remove the tumor. Parents should be aware of the risks involved with surgery.
Monitor kidney function
Assess input and output to ensure that the child is urinating
Risk of tumor rupture-do not palpate abdomen
Pediatric Pain Medication Notes:
Meperidine should not be given to children, especially children with sickle cell disease.
Codeine and tramadol are rarely used in pediatrics.