NCLEX-RN: Pediatric Nursing

Pediatric Nursing:DISORDERS OF THE BLOOD

Focus topic: Pediatric Nursing

The circulatory system, a continuous circuit, is the mechanical conveyor of the body constituent called blood. Blood, composed of cells and plasma, circulates through the body and is the means by which oxygen and nutrients are transported to the tissues.

Pediatric Nursing: System Assessment

Focus topic: Pediatric Nursing

A. History.

  •  Perinatal and birth history, significant family history.
  • Recent illnesses or appearance of bleeding or bruising, dietary history.

B. Inspection.

  •  Assess skin color for general pallor (especially mucous membranes).
  •  Observe for bruising or petechiae.
  •  Evaluate activity level and general level of energy.
  •  Plot growth on curve, noting downward trends.

C. Palpation.

  • . Palpate liver and spleen margins, noting enlargement.
  • Palpate peripheral pulses for quality and rate.
  • Note any enlarged lymph nodes.

D. Percussion may percuss liver and spleen.
E. Auscultation.

  •  Note heart rate and respiratory rate.
  •  Evaluate cardiac murmur.
  •  Assess blood pressure.

F. Evaluate the CBC.

Pediatric Nursing: Red Blood Cell Disorders

Focus topic: Pediatric Nursing

Pediatric Nursing: Anemia

Focus topic: Pediatric Nursing

Definition: A deficit of red blood cells (RBCs) or hemoglobin caused by impairment of red blood cell production or increased erythrocyte destruction. A reduced oxygen-carrying capacity results, with decreased oxygen available to the tissues.

Assessment
A. Classifications of anemia.

  •  Etiology/pathology: RBC hemolytic, decreased RBC production, or from acute or chronic blood loss.
  •  Morphology: based on RBC size, shape, or color.

B. Assess for general changes in behavior: listlessness, fatigue, poor suck, pica, pallor, tachypnea, tachycardia or shortness of breath, cardiac murmur.

C. Assess for central nervous system manifestations: headache, dizziness, irritability, decreased attention span, apathy, or depression.
D. Observe for signs of shock (poor peripheral perfusion; cool, clammy skin; tachycardia and decreased blood pressure) in severe cases.
E. Determine if nutritional deficiency is present; iron, folic acid, vitamin B12.
F. Evaluate tests for impairment of red blood cell production: red cell, aplastic, or hemolytic anemia or leukemia.
G. Look for sources of blood loss (GI tract) with stool hemoccult exam.
H. Consider racial/ethnic background for genetic causes of anemia.

Implementation
A. Prepare child for blood draws.
B. Decrease oxygen demands (providing rest, quiet activities).
C. Support RBC production by maintaining nutritious diet with vitamin and iron supplements, excellent hygiene, adequate rest, and avoidance of exposure to infections.
D. Teach parents that stools will be dark with iron supplements. Vomiting and diarrhea can occur.
E. Monitor blood transfusions and observe for signs of transfusion reactions.
F. Administer iron preparations or injections by special method (Z-track if severe iron deficiency is present) and take special precautions.
G. Support family, make appropriate consults/referrals, support growth and development, prepare for discharge.

Pediatric Nursing

 

Pediatric Nursing: Sickle Cell Anemia

Focus topic: Pediatric Nursing

Definition: An autosomal disorder in which red blood cells sickle when under low-oxygen tension (hemoglobin A is partly or completely replaced by hemoglobin S). Sickled erythrocytes hemolyze or cause poor blood flow through capillaries and decrease oxygen delivery to tissues. Tissue damage can occur throughout the body and complications result from delayed growth and development, acute and chronic pulmonary dysfunction, stroke, aseptic necrosis of the hip and shoulder, retinopathy, dermal ulcers, severe and chronic pain, and psychosocial problems.

Characteristics
A. Usually confined to African Americans, but may be present in people from Mediterranean areas.
B. Asymptomatic until 4–6 months of age because of presence of fetal hemoglobin. Now diagnosed with routine newborn blood screening (hemoglobin electrophoresis).

C. Sickle cell disease (SCD) may also be diagnosed prenatally or in any child or adult with the sickleturbidity test (Sickledex).

Assessment
A. Assess major symptoms.

  •  Usually asymptomatic until under stress (illness, dehydration, excessive exercise, high altitude).
  •  Severe chronic anemia pallor.
  •  Periodic crises with abdominal and joint pain.
  •  Lethargy and listlessness.
  •  Irritability.
  •  High fever
  •  Enlarged spleen from increased activity.
  •  Jaundice from excessive blood cell destruction.
  •  Widening of the marrow spaces of the bones.
  •  Renal dysfunction.
  •  Decreased growth.

B. Vaso-occlusive crisis

  •  Most frequent type.
  •  Caused by occlusion of the small blood vessels producing distal ischemia and infarction.
  •  Beginning of crises may be characterized by the swelling of the hands and feet or decreased appetite, irritability, or fever.
  •  May experience pain and swelling in abdomen.
  • Cerebral vascular accident (CVA) or stroke possible at any age.

C. Sequestration crises.

  •  Occurs usually in children under 5 years of age.
  •  Caused by pooling of blood in spleen, with circulatory collapse.
  •  Enlargement of spleen and loss of spleen function.

D. Acute chest syndrome (new pulmonary infiltrate).

  • Chest pain.
  •  Fever.
  •  Cough, wheezing, tachypnea, and hypoxia.

E. Aplastic crisis: profound anemia caused by diminished erythropoiesis.

  •  Pallor, lethargy, headache, fainting.
  • Transfusion of packed RBCs only treatment.

Implementation
A. Alleviate pain with analgesics.
B. Prevent dehydration with intravenous infusion, if necessary, and increased fluid intake; hydration can reduce sickling.
C. Supplemental oxygen may be administered to optimize tissue oxygenation.
D. Hydroxyurea, which increases the production of fetal hemoglobin that interferes with the RBC sickling process and protects against future sickling episodes.

E. Antibiotics for acute infections (acute chest syndrome).
F. Keep child warm.
G. Offer parents genetic counseling.
H. During sequestration crises, supervise blood transfusions.
I. Teaching: emphasizing preventing crises, signs of crises, emotional support, prescribed activity, supporting development, safe activities for child to participate in, Medic-Alert® bracelet.
J. Discharge planning with appropriate referrals.
K. Genetic counseling for families and young adults considering child rearing.
L. Routine prophylactic Veetids (penicillin V) therapy.
M. Immunizations against HIB, pneumococcal, and meningococcal organisms according to specific recommendations and other routine immunizations.
N. May require splenectomy.
O. Hematopoietic stem cell transplantation a possibility.

Pediatric Nursing: Thalassemias

Focus topic: Pediatric Nursing

Definition: An inherited group of hemolytic anemias caused by too few hemoglobin polypeptide chains. The disorders are categorized by the site of the inadequate globin synthesis (alpha thalassemia, beta thalassemia; one [minor] or two [major] chains may be lacking). A chronic condition. Most often seen in individuals of Mediterranean descent.

Assessment
A. Assess for bronze tone to skin or pallor.
B. Observe for jaundice; serum bilirubin elevated.
C. Enlarged head, frontal and parietal bossing, severe maxillary hyperplasia, malocclusion; wide set eyes and flattened nose.
D. Hepatosplenomegaly.
E. Assess CBC, reticulocyte count, serum iron level, total iron binding capacity, hemoglobin electrophoresis, HbA and HbF levels to confirm the diagnosis. The CBC will reflect microcytic hypochromic RBCs.

Implementation
A. Supportive: rest, decreased activity.
B. Administer packed red cells.
C. Chelating agent for excess iron, Desferal (deferoxamine).
D. Prepare for splenectomy if transfused cells are rapidly destroyed by spleen.
E. Teaching: Explain prognosis and treatment regimen to parents and child, need for frequent transfusions, genetic counseling, support in adapting to chronic illness, appropriate referrals.

F. Routine prophylactic Veetids therapy.
G. Immunizations against HIB, pneumococcal, and meningococcal organisms according to specific recommendations and other routine immunizations.

Pediatric Nursing: Blood Disorders

Focus topic: Pediatric Nursing

Pediatric Nursing: Infectious Mononucleosis

Focus topic: Pediatric Nursing

Definition: An acute, self-limited infectious disease, caused primarily by the Epstein–Barr virus, which affects the epithelial cells and the B lymphocytes. Most common min individuals < age 25.

Assessment
A. The incubation period is 4–6 weeks. The infectious period is unknown, the virus is commonly shed before the clinical onset of disease until 6 months after recovery. The acute illness usually lasts 2–4 weeks followed by a gradual recovery.
B. Blood test (“monospot”) used to make diagnosis, with clinical signs.
C. Assess for specific symptoms of variable severity.

  •  Malaise, fatigue, headache, nausea, abdominal pain.
  •  Sore throat with pharyngitis (may be severe).
  •  Prolonged fever (may last 2 weeks).
  •  Enlargement of the lymph nodes.
  •  Splenomegaly.
  • Skin rashes (viral exanthem).

Implementation
A. Provide symptomatic and supportive measures  no specific treatment.

  •  Initially bed rest is indicated, promote rest.
  •  Encourage high fluid intake. Watch for dehydration if unable to swallow due to sore swollen throat.
  •  Increase in activity should be gradual.
  •  Tylenol is given for fever, chills, and muscle pain.
  •  Prevent secondary infections by limiting contacts while acutely ill.
  •  Strenuous activity and contact sports during acute illness should be avoided as long as the spleen is enlarged  to prevent splenic rupture.

Pediatric Nursing: Hemophilia

Focus topic: Pediatric Nursing

Definition: A sex-linked disorder in which certain factors necessary for coagulation of the blood are missing. Sex-linked traits are passed from unaffected carrier females to affected males along with the X chromosome.

Characteristics
A. Hemophilia A—Factor VIII deficiency: treated with monoclonal factor VIII concentrate and often DDAVP (for its vasoconstrictor action).
B. Hemophilia B—Factor IX deficiency (Christmas disease): treated with purified, concentrated Factor IX.

Assessment
A. Assess for type A or B.

  •  Possible bleeding tendency in neonatal period because factors are not passed through the placenta.
  •  Excessive bruising.
  •  Large hematomas from minor trauma.
  •  Persistent bleeding from minor injuries.
  •  Hemarthrosis with joint pain, swelling, and limited movement.
  •  Abnormalities in clotting studies PT, partial thromboplastin time (PTT), fibrinogen, Factor VIII or IX assay.
  •  Possible progressive degenerative changes with osteoporosis, muscle atrophy, and fixed joints.

B. Assess for type C.

  •  Usually appears as a mild bleeding disorder.
  •  Autosomal dominant trait with both sexes affected.

Implementation
A. Prevent bleeding.

  •  Protect child from environment by padding crib and playpen.
  •  Supervise child carefully when child is learning to walk.

B. Treatment if bleeding occurs:

  • Apply cold compresses and pressure.
  •  Hemarthrosis (effusion of blood into joint).
    a. Immobilize joint initially.
    b. Initiate passive range of motion within 48 hours to prevent stiffness.
    c. Manage pain adequately.
  •  Immobilize site of bleeding.
  •  Administer needed factors or blood products, monitor for transfusion reaction.
  •  Multidisciplinary education program genetic counseling, home management, support growth and development, family needs and assistance, appropriate referrals.
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Pediatric Nursing: HIV and Children

Focus topic: Pediatric Nursing

Definition: Considered to have acquired immune deficiency syndrome (AIDS) when at least one complicating illness develops or when CD4 drops below 200. HIV is a viral infection that interferes with the body’s ability to fight the organisms that cause disease.

Characteristics
A. Less than 2% of the people infected with HIV in the United States are children or adolescents due to treatment of pregnant women with HIV prenatally, specific obstetric procedures to prevent transmission of HIV during labor, and increased prenatal counseling and testing for HIV.

  •  The incidence of HIV in infants and children is approximately 200 children annually, stable for several years (CDC, 2014).
  •  Heterosexual intimacy and infection through IV drug use are the most common modes of transmission for women and adolescent girls.
  •  HIV may also be transmitted through breast milk.

B. Symptoms and complications of HIV and death result from opportunistic infections from viruses, parasites, and (unlike adults) bacteria.
C. Transmission (see above paragraph).
D. Signs for HIV in children.

  • Repeated or persistent respiratory tract infections, including otitis media and sinusitis.
  •  Severe bacterial infections.
  • Opportunistic infections such as Pneumocystis jiroveci (PCP) or cryptosporidiosis.
  •  Poor response to treatment.

E. Frequently present, somewhat suggestive signs.

  •  Skin lesions.
  •  Failure to thrive.
  •  Chronic diarrhea.
  •  Thrush.
  •  Hepatosplenomegaly.
  • Anemia, thrombocytopenia, neutropenia.
  • Small or absent lymph nodes, tonsils, and adenoids.

Implementation
A. If an infected woman conceives, anti-HIV drugs are fairly effective.
B. Drug treatment.

  •  Woman may receive Retrovir (zidovudine [ZDV], also called AZT) by mouth during the second and third trimesters (last 6 months) of pregnancy with two other antiviral drugs. It will be delayed after the first 12 weeks of pregnancy if the viral load is low enough.
  •  Antiviral drugs given IV during labor and delivery.
  •  Retrovir given daily to the newborn for 6 weeks until the newborn is confirmed HIV negative. If positive to HIV, the infant will begin to receive combination antiviral drug therapy.

C. Cesarean delivery decreases baby’s risk of acquiring HIV infection.
D. Drugs given to prevent opportunistic infections.

  •  Children under 1 year will be given Bactrim to prevent PCP infection.
  •  Transmission of infections, such as chickenpox, to the HIV-infected child is a danger. Varicella immune globulin will be given within 96 hours of exposure to varicella or zoster infection.
  •  Infants under 3 months of age will be tested for tuberculosis with purified protein derivative (PPD).
  •  In most cases, the usual child immunization schedule is followed (may depend on the child’s CD4+ count). Whether to administer live virus vaccines (MMR, varicella, rotavirus) determined for each child.

E. CD4+ lymphocyte counts, HIV RNA assays assess an infected young child’s immune status, response to therapy, risk for disease progression, and need for PCP prophylaxis after 1 year of age.

  •  Various combinations of antiviral drugs have been recommended based on the age of the child. (Please refer to the most current guidelines for HIV-infected children Guidelines for the Use of Antiretroviral Agents in Pediatric HIV Infection What’s New in the Guidelines. [Last updated: February 12, 2014; last reviewed: February 12, 2014] http://aidsinfo.nih.gov/guidelines /html/2/pediatric-treatment-guidelines/0)
  •  In general, children are treated aggressively because of the rapid progression of HIV in children.

F. Social issues.

  •  A child with HIV and open skin sores, or who engages in potentially dangerous behavior, such as biting, should not attend child care.
  •  HIV-infected children should participate in as many routine childhood activities as their physical condition allows.
  •  Interaction with other children enhances social development and self-esteem.

G. Standard Precautions should be practiced.

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