NCLEX: Health Promotion and Maintenance

Health Promotion and Maintenance : HEMATOLOGICAL SYSTEM

Focus topic: Health Promotion and Maintenance

I. LEUKEMIA

Focus topic: Health Promotion and Maintenance

A. Introduction: Known as “cancer of the blood,” leukemia is the most common form of childhood cancer, with an incidence of 4/100,000. Acute leukemia is basically a malignant proliferation of white blood cell (WBC) precursors triggered by an unknown cause and affecting all blood-forming organs and systems throughout the body. The onset is typically insidious, and the disease is most common in preschoolers (age 2–6 years).

B. Assessment:

Focus topic: Health Promotion and Maintenance

1. Major problem—leukopenia: decreased WBCs/increased blasts (overproduction of immature, poorly functioning WBCs).

2. Bone marrow dysfunction results in:

  • Neutropenia: multiple prolonged infections.
  • Anemia: pallor, weakness, irritability, shortness of breath.
  • Thrombocytopenia: bleeding tendencies (petechiae, epistaxis, bruising).

3. Infiltration of reticuloendothelial system (RES): hepatosplenomegaly, abdominal pain, lymphadenopathy.
4. Leukemic invasion of CNS: increased intracranial pressure/leukemic meningitis.
5. Leukemic invasion of bone: pain, pathological fractures, hemarthrosis.

C. Analysis/nursing diagnosis:

Focus topic: Health Promotion and Maintenance

  • Risk for infection related to neutropenia.
  • Risk for injury related to thrombocytopenia.
  • Altered nutrition, less than body requirements, related to loss of appetite, vomiting, mouth ulcers.
  • Pain related to disease process and treatments (e.g., hemarthrosis, bone pain, bone marrow aspiration).
Health Promotion and Maintenance
  • Activity intolerance related to infection and anemia.
  • Self-esteem disturbance related to disease process and treatments (e.g., loss of hair with chemotherapy, moon face with prednisone).
  •  Anticipatory grieving related to life-threatening illness.
  • Knowledge deficit related to diagnosis, treatment, prognosis.

D. Nursing care plan/implementation:

Focus topic: Health Promotion and Maintenance

1. Goal: maintain infection-free state.

  • Standard precautions to prevent infection.
  • Use good hand washing technique.
  • Ongoing evaluation of sites for potential infection (e.g., gums).
  • Provide meticulous oral hygiene.
  • Keep record of vital signs, especially temperature.
  • Provide good skin care.
  • Screen staff and visitors (especially children)— restrict anyone with infection.
  • Protective isolation/reverse isolation to minimize exposure to potentially life-threatening infection.
  • Discharge planning: return to school, but isolate from chickenpox or known communicable diseases.

2. Goal: prevent injury.

  • Avoid IMs/IVs if possible, due to bruising and bleeding tendencies.
  • Do not give aspirin or medications containing aspirin, which will interfere with platelet formation, thus increasing the risk of bleeding.
  • Use soft toothbrush to avoid trauma to gums, which may cause bleeding and infection.
  • Avoid “per rectum” suppositories, due to probable rectal ulcers.
  • Supervise play/activity carefully to promote safety and prevent excessive bruising or bleeding.

3. Goal: promote adequate nutrition.

  • Diet: high calorie, high protein, high iron.
  • Encourage extra fluids to prevent constipation or dehydration.
  • I&O, daily weights, to monitor fluid and nutritional status.
  • Allow child to be involved with food selection/ preparation; allow child almost any food he or she tolerates, to encourage better dietary intake.
  • Thoroughly wash/peel fresh fruits and vegetables if child is neutropenic (or avoid eating these foods).
  • Serve frequent, small snacks to increase fluid and caloric consumption.
  • Offer dietary supplements to increase caloric intake.
  • Encourage local anesthetics such as dextromethorphan throat lozenges (Chloraseptic) before meals to allow child to eat without pain from oral mucous membrane ulcers.

4. Goal: relieve pain.

  • Offer supportive alternatives: extra company, back rub. Offer complementary therapies: meditation, visualization (if age appropriate).
  • Administer medications regularly, before pain becomes excessive.
  • Use beanbag chair for positional changes.
  • Avoid excessive stimulation (noise, light), which may heighten perception of pain.

5. Goal: promote self-esteem.

  • Stress what child can still do to keep the child as independent as possible.
  • Encourage performance of ADLs as much as possible to foster a sense of independence.
  • Provide diversion/activity as tolerated.
  • Give lots of positive reinforcement to enhance a sense of accomplishment.
  • Provide realistic feedback on child’s appearance; offer suggestions, such as a wig or cap to cover alopecia secondary to chemotherapy.
  • Encourage early return to peers/school to avoid social isolation.

6. Goal: prevent complications related to leukemia/prolonged immobility/treatments.

  • Inspect skin for breakdown, especially over bony prominences, due to poor nutritional intake and limited mobility due to bone pain.
  • Anticipate need for and administer (per physician’s order) multiple transfusions of platelets, packed red blood cells (RBCs), etc.
  • Check for hemorrhagic cystitis; push fluids (especially with Cytoxan).
  • Check for constipation or peripheral neuropathy (especially with vincristine). Refer to Chapter 8 for specific information on chemotherapy.

7. Goal: assist child and parents to cope with lifethreatening illness.

  • Teach rationale for repeated hospitalizations, multiple invasive tests/treatments, long-term follow-up care.
  • Encourage compliance with all aspects of therapy, to increase chances of survival.
  • Support family members and their coping mechanisms.
  • Offer factual information regarding ultimate prognosis (“80% cure” for acute lymphocytic leukemia [ALL]).
  • If death appears imminent, assist family to cope with dying and death.

E. Evaluation/outcome criteria:

Focus topic: Health Promotion and Maintenance

  • Child is maintained in infection-free state.
  • Injuries are prevented or kept to a minimum.
  • Adequate nutrition is maintained.
  • Child is free from pain or can live with minimum level of pain.
  • Child’s self-esteem is maintained; child is treated as living (not dying).
  • Complications are prevented or kept to a minimum.
  • Child and family use positive coping mechanisms to deal with illness.

II. SICKLE CELL ANEMIA

Focus topic: Health Promotion and Maintenance

A. Introduction: Sickle cell anemia is a congenital hemolytic anemia resulting from a defective hemoglobin (Hgb) molecule (hemoglobin S). It is most common in African Americans (8% have sickle cell trait) and in people of Mediterranean, Hispanic, and Middle Eastern descent. The diagnosis is usually made during the toddler or preschool years, during the first crisis episode following an infection. There is also the need to differentiate between sickle cell trait (Sickledex test) and sickle cell anemia (hemoglobin electrophoresis). Sickle cell anemia has no known cure.

B. Assessment:

Focus topic: Health Promotion and Maintenance

  • Increased susceptibility to infection (cause: unknown; most common cause of death in children under 5 years).
  • Inherited as autosomal recessive disorder Genetic transmission of sickle cell anemia.
  • Precipitated by conditions of low oxygen tension, dehydration, vascular obstruction, increased blood viscosity, infection.
  • Signs of anemia:
    a. Pallor (in dark-skinned children, do not rely on pallor alone—check hemoglobin [Hgb] and hematocrit [Hct]).
    b. Jaundice, due to excessive hemolysis.
    c. Irritability, lethargy, anorexia, malaise.
  • Vaso-occlusive crisis: severe pain (variable sites, e.g., chest, back, abdomen), fever, swelling of hands and feet, joint pain and swelling, all related to hypoxia, ischemia, and necrosis at the cellular level. Most common; usually non–life threatening.
Health Promotion and Maintenance
  • Splenic sequestration crisis: blood is sequestered (pooled) in spleen; precipitous drop in hemoglobin levels and blood pressure, increased pulse rate, shock, and ultimately death from profound anemia and cardiovascular collapse.

C. Analysis/nursing diagnosis:

Focus topic: Health Promotion and Maintenance

  • Altered tissue perfusion related to anemia and occlusion of vessels.
  • Pain related to vaso-occlusion.
  • Impaired physical mobility related to pain, immobility.
  • Knowledge deficit related to disease process and treatment (e.g., prevention of sickling or infection; genetic counseling).

D. Nursing care plan/implementation:

Focus topic: Health Promotion and Maintenance

1. Goal: prevent sickling.

  • Avoid conditions of low oxygen tension (hypoxia), which causes RBCs to assume a sickled shape.
  • Provide continuous extra fluids to prevent dehydration, which causes sluggish circulation. State specific amounts to be consumed rather than “encourage fluids.” Avoid temperature extremes.
  • Avoid activities that may result in overheating, to prevent dehydration; suggest appropriate clothes; limit time in sun.
  • If dehydrated due to acute illness, supplement with IV fluids and additional oral fluids to reestablish fluid balance.

2. Goal: maintain infection-free state.

  • Standard precautions to prevent infection.
  • Use good hand washing technique.
  • Evaluate carefully, check continually for potential infection sites, which may either lead to death due to sepsis or precipitate sickle cell crisis.
  • Teach importance of prevention of sickle cell crisis: adequate fluids and nutrition; frequent medical checkups; keep away from known sources of infection.
  • Stress need to report early signs of infection (chest crisis) promptly to physician.
  • Need to balance prevention of infection with child’s need for a “normal” life.
  • Administer yearly influenza vaccine.

3. Goal: provide supportive therapy during crisis.

  • Provide bedrest/hospitalization during crisis to decrease the body’s demand for oxygen.
  • Relieve pain due to infarction of tissues by administering pain medications as ordered; handle gently and use proper positioning techniques.
  • Apply heat (never cold) to affected painful areas to increase blood flow (vasodilation) and oxygen supply.
  • Administer oxygen, as ordered, to relieve hypoxia and prevent further sickling.
  • Administer blood transfusions, as ordered, to correct severe anemia. Complication: If hypertransfusion programs are implemented, child may develop “iron overload.” Desferal chelates the iron so that it can be excreted through the urine or bile to help reduce this complication.
  • Standard medications: hydroxyurea, folic acid.
  • Monitor fluid and electrolyte balance: I&O, weight, electrolytes.
  • Perform ADLs for child if unable to care for own needs; encourage self-care as soon as possible to promote independence. Avoid stress and fatigue.

4. Goal: teach child and family about sickle cell anemia.

  • Provide factual information based on child’s developmental level.
  • When asked, offer information regarding prognosis (no known cure).
  • Encourage child to live as normally as possible.
  • Genetic screening and counseling Genetic transmission of sickle cell anemia.

E. Evaluation/outcome criteria:

Focus topic: Health Promotion and Maintenance

  • Sickling is prevented or kept to a minimum.
  • Child is maintained in infection-free state.
  • Child/family verbalize that they can cope adequately with crisis.
  • Child/family verbalize their understanding about disease, its management, and its prognosis.

III. HEMOPHILIA

Focus topic: Health Promotion and Maintenance

A. Introduction: Hemophilia is a bleeding disorder inherited as a sex-linked (X-linked) recessive trait; that is, it occurs only in men but is transmitted by women carriers who are symptom free Genetic transmission of hemophilia. Hemophilia results in a deficiency of one or more clotting factors; it is necessary to determine which clotting factor is deficient and to what extent. Classic hemophilia (hemophilia A), a lack of clotting factor VIII, accounts for 75% of all cases of hemophilia.

B. Assessment:

Focus topic: Health Promotion and Maintenance

1. Major problem is bleeding.

  • In newborn boy: abnormal bleeding from umbilical cord, prolonged bleeding from circumcision site.
  • In toddler boy: excessive bruising, possible intracranial bleeding, prolonged bleeding from cuts or lacerations.
  • General: hemarthrosis, petechiae, epistaxis, frank hemorrhage anywhere in body, anemia.
Health Promotion and Maintenance

2. Need to determine which clotting factor is deficient/missing and extent of deficiency:

  • Mild: child has 5% to 50% of normal amount of clotting factor.
  • Moderate: child has 1% to 5% of normal amount of clotting factor.
  • Severe: child has less than 1% of normal amount of clotting factor.
  • Definitive test: PTT

C. Analysis/nursing diagnosis:

Focus topic: Health Promotion and Maintenance

  • Risk for injury related to bleeding tendencies.
  • Pain related to hemarthrosis.
  • Impaired physical mobility related to bleeding and pain.
  • Knowledge deficit related to home care and follow-up.

D. Nursing care plan/implementation:

Focus topic: Health Promotion and Maintenance

1. Goal: prevent injury and possible bleeding.

  • Provide an environment that is as safe as possible (e.g., toys with no sharp edges, child’s safety scissors).
  • Use soft toothbrush to prevent trauma to gums. Wear safety equipment in PE; no contact sports.
  • When old enough to shave, use only electric razor (no straight-edge razors).
  • Avoid IMs/IVs—but when absolutely necessary, treat as arterial puncture; that is, apply direct pressure to the site for at least 5 min after withdrawing needle.
  • Do not use aspirin or medication containing aspirin (prolongs bleeding/clotting time). Caution with NSAIDs (inhibit platelet function).

2. Goal: control bleeding episodes when they occur.

  • Local measures: RICE (Rest, Ice, Compression, Elevation); keep immobilized during acute bleeding episodes only. For epistaxis: child should sit up and lean slightly forward.
  • Systemic measures: administer clotting antihemophilic factor (factor VIII or DDAVP) via IV infusion. Note: These are blood products, so a transfusion reaction is possible.
  • Note: cryoprecipitate (a blood product) is no longer used due to risk of transmission of hepatitis and HIV.

3. Goal: prevent long-term disability related to joint degeneration.

  • Keep immobilized during period of acute bleeding and for 24 to 48 hours afterward to allow blood to clot and to prevent dislodging the clot.
  • Administer prescribed pain medications before physical therapy sessions.
  • Begin prescribed exercise program, starting with passive range of motion (ROM) and gradually advancing to active ROM, then full exercise program, as tolerated, to maintain maximum joint function. Monitor weight to prevent ↑ strain on joints (especially knees).
  • Avoid: prolonged immobility, braces, splints—which can lead to permanent deformities and loss of mobility.

4. Goal: promote independence in management of own care.

  • Encourage child to assume responsibility for choosing safe activities.
  • Encourage child to attend regular school as much as possible; provide support through school nurse.
  • Advise child to wear Medic Alert bracelet.
  • Caution parents to avoid overprotecting child.
  • Offer child chance to self-limit activities within appropriate limits (parents can offer guidance).
  • Assist child to cope with life-threatening disorder with no known cure.

5.Goal: health teaching.

  • Between 9 and 12 years of age: child can be taught to self-administer clotting factor IV (before this, family can perform).
  • As child enters adolescence: begin to discuss issues such as realistic vocations, insurance coverage, genetic transmission Genetic transmission of hemophilia.

E. Evaluation/outcome criteria:

Focus topic: Health Promotion and Maintenance

  • Serious injuries are prevented; bleeding is kept to a minimum.
  • Episodes of bleeding are controlled by prompt, effective intervention.
  • There are no long-term disabilities.
  • Child is able to manage own care independently, with minimum supervision.

Health Promotion and Maintenance : IMMUNOLOGICAL SYSTEM

Focus topic: Health Promotion and Maintenance

I. RECOMMENDED SCHEDULE FOR ACTIVE IMMUNIZATION OF HEALTHY INFANTS AND CHILDREN

Focus topic: Health Promotion and Maintenance

II. ASSESSMENT: common side effects of immunizations (occur 24 to 48 hours after immunization except as noted):

  • Soreness, redness, tenderness, or lump at injection site.
  • Fever: brief, mild to moderate.
  • Crankiness and fussiness; anorexia; drowsiness.
  • Measles—coryza and rash 7 to 10 days after immunization.
  • Rubella—arthralgia and arthritis-like symptoms 2 weeks after immunization.

III. NURSING INTERVENTIONS/HOME CARE for infant or child who has been immunized:

  • Explain to parents the reason for each immunization and common side effects.
  • Suggest acetaminophen for fever or discomfort.
  • Extra affection and closeness—cuddling, soothing, rocking.
  • Teach parents to notify physician of untoward, serious, or prolonged side effects.

IV. CONTRAINDICATIONS/PRECAUTIONS TO IMMUNIZATIONS

Focus topic: Health Promotion and Maintenance

  • Child who has a severe febrile illness (e.g., URI, gastroenteritis, or any fever).
  • Child with alteration in skin integrity: rash, eczema.
  • Child with alteration in immune system; steroids; chemotherapy, radiation therapy; human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) (no live virus vaccine).
  • Child with a known allergic reaction to previous immunization or substance in the immunization.
  • Recent recipient of blood/blood products.

V. CHILDHOOD COMMUNICABLE DISEASES (Communicable Diseases of Childhood). Basic principles of care:

  • Standard precautions to prevent communicability/ infection.
  • Fever control with acetaminophen.
  • Extra fluids for hydration.
  • General home care procedures: comfort measures/supportive care.

Streptococcus Infections/Sequelae

Introduction: Group A β-hemolytic streptococcus is a common infectious organism that causes illness in children and is highly contagious. In themselves, the diseases caused by streptococcus do not seem very serious (e.g., strep throat, otitis media, impetigo, or scarlet fever). The most common treatment for strep is a full course of antibiotic therapy: 10 days of penicillin (or, if allergic, erythromycin). With adequate therapy, generally no sequelae are seen. If the strep is not treated, or is only partially treated, the sequelae include serious systemic diseases, with potentially longterm effects. If the effect is manifested primarily in the heart (carditis), it is acute rheumatic fever. If the effect is manifested primarily in the kidneys, it is acute glomerulonephritis.

Health Promotion and Maintenance : INTEGUMENTARY SYSTEM

Focus topic: Health Promotion and Maintenance

I. INFANTILE ECZEMA (ATOPIC DERMATITIS)

Focus topic: Health Promotion and Maintenance

A. Introduction: Eczema is an allergic skin reaction, most commonly to foods (e.g., cow’s milk, eggs). It is most common in infants and young children (under 2 years). Infantile eczema generally undergoes permanent, spontaneous remission by age 3 years; however, approximately 50% of children who have had infantile eczema develop asthma during the preschool or school age years.

Health Promotion and Maintenance
Health Promotion and Maintenance
Health Promotion and Maintenance
Health Promotion and Maintenance
Health Promotion and Maintenance
Health Promotion and Maintenance
Health Promotion and Maintenance

B. Assessment:

Focus topic: Health Promotion and Maintenance

  • Erythematous lesions, beginning on cheeks and spreading to rest of face and scalp.
  • May spread to rest of body, especially in flexor surfaces (e.g., antecubital space).
  • Lesions may ooze or crust over.
  • Severe pruritus, which may lead to secondary infection.
  • Lymphadenopathy near site of rash.
  • Unaffected skin tends to be dry and rough.
  • Systemic manifestations are rare—but child may be irritable, cranky.

C. Analysis/nursing diagnosis:

  • Impaired tissue integrity related to lesions.
  • Pain related to pruritus.
  • Risk for (secondary) infection related to breaks in the skin (first line of defense) and itching.
  • Knowledge deficit related to care of child with eczema, prognosis, how to prevent exacerbations.

D. Nursing care plan/implementation:

Focus topic: Health Promotion and Maintenance

1. Goal: promote healing of lesions.

  • Wet method: frequent tepid baths (up to four times a day) followed by immediate application of a lubricant while the skin is still moist; no soap or use very mild, nonperfumed soap (e.g., Dove, Neutrogena); most useful method if child lives in a dry climate.
  • Dry method: infrequent baths; cleanse skin with nonlipid, hydrophilic agent (e.g., Cetaphil); most useful method if child lives in a humid climate.
  • Can add cornstarch to bath water to relieve itching and promote healing; keep skin well hydrated by applying emollients containing petrolatum or lanolin, which are occlusive and prevent evaporation of moisture.
  • Apply wet soaks with Burow’s solution (aluminum acetate solution; topical astringent and antiseptic); wet soaks should not be used for more than 3 days at a time
  • Protect child from possible sources of infection; standard precautions to prevent infection.
  • Absolutely no immunizations during acute exacerbations of eczema because of the possibility of an overwhelming dermatitis, allergic reaction, shock, or even death.
  • Apply topical creams/ointments as prescribed: A and D emollient ointment, hydrocortisone cream to promote healing.

2. Goal: provide relief from itching/keep child from scratching.

  • Administer systemic oral antihistamines as ordered (e.g., Benadryl or Atarax) to break itch-scratch cycle. Most useful at bedtime when itching tends to increase.
  • Keep nails trimmed short—may need mittens (preferable not to use elbow restraints, because the antecubital space is a common site for eczema).
  • Use clothes and bed linens that are nonirritating, that is, pure cotton (no wool or blends).
  • Institute elimination/hypoallergenic diet:
    (1)No milk or milk products.
    (2)Change to lactose-free formula (e.g., Isomil).
    (3)Avoid: eggs, wheat, nuts, beans, chocolate.
  • No stuffed animals or hairy dolls.

3. Goal: provide discharge planning/teaching for parents and child.

  • Include all above information.
  • Include information on course of disease: characterized by exacerbations and remissions throughout early years.
  • Include information on prognosis: 50% to 60% will go into spontaneous (and permanent) remission during preschool years; 40% to 50% will develop asthma/hay fever during school-age years.

E. Evaluation/outcome criteria:

Focus topic: Health Promotion and Maintenance

  • Lesions heal well, without secondary infection.
  • Adequate relief from itching is achieved.
  • Parents verbalize understanding of eczema, prognosis, and how to prevent exacerbations.

II. INFESTATIONS

Focus topic: Health Promotion and Maintenance

A. Lice (pediculosis)

1. Introduction: In children, the most common form of lice is pediculosis capitis, or head lice. This parasite feeds on the scalp, and its saliva causes severe itching. Head lice are frequently associated with the sharing of combs and brushes, hats, and clothing; thus, they are more common in girls, especially those with long hair. Lice are also associated with overcrowded conditions and poor hair hygiene.

2. Assessment:

  • Severe itching of scalp.
  • Visible eggs/nits on shafts of hair.

3. Analysis/nursing diagnosis:

  • Impaired skin integrity related to infestation of scalp with lice.
  • Risk for impaired skin integrity related to severe pruritus of scalp.
  • Knowledge deficit related to transmission and prevention of disease and treatment regimen.

4. Nursing care plan/implementation:

a. Goal: eradicate lice infestation. Apply permethrin (Nix) as drug of choice for infants and children—rub shampoo in for 4 to 5 minutes, then comb with fine-tooth comb to remove dead lice and nits (eggs).

b. Goal: prevent spread of lice.

  • Wear gloves and cap to protect self.
  •  Inspect other family members; treat prn with pediculocide.
  • Wash all clothes and linens to kill any lice that may have fallen off the child’s hair.
  • Encourage short hair, if acceptable.
  • Teach preventive measures: do not share comb, brushes, hats.

5. Evaluation/outcome criteria: lice are eradicated and do not spread.

B. Pin worms (enterobiasis)

1. Introduction: In children, the most common helminthic infestation is pinworms. Infestation usually occurs when the child places fingers (and the pinworm eggs) into the mouth. Breaking the anus-to-mouth contamination cycle can best be accomplished by good hygiene, especially hand washing before eating and after toileting. If one family member has pinworms, it is highly likely that other family members are also infested; therefore, treat the entire family to eradicate the parasite. Pinworms are easily eradicated with antiparasitic medications.

2. Assessment:

  • Intense perianal itching.
  • Visible pinworms in the stool.
  • Vague abdominal discomfort.
  • Anorexia and weight loss.

3. Analysis/nursing diagnosis:

  • Risk for infection/injury related to the anus-to- mouth contamination cycle of pin worm infestation, severe rectal itching.
  • Knowledge deficit related to transmission and prevention of disease and treatment regimen.

4. Nursing c a re plan/ implementation:

a. Goal: eradicate pin worm infestation. Treat all family members simultaneously with an antiparasitic agent (e.g., Vermox, Povan).
b. Goal: prevent spread of pin worms.

  • Launder all underwear, bed linens, and towels in hot soapy water to kill eggs.
  • Teach family members the importance of good hygiene, especially hand washing before eating (or preparing food) and after toileting. Stress to children to keep their fingers out of their mouths.

5. Evaluation/out come criteria: Pin worms are eradicated and do not spread; re-infestation does not occur.

FURTHER READING/STUDY:

Resources:

 

Leave a Reply

Your email address will not be published. Required fields are marked *