the nursing diagnoses. Nursing Care Plan 47.1 may be used as a guide in planning nursing care for the child with a hematologic disorder. Refer to Chapter 36 for additional information related to pain management.
Children’s responses to hematologic disorders and their treatments will vary, and nursing care should be indi- vidualized based on the child’s and family’s responses to illness. Other conditions may contribute to these nursing diagnoses and must also be considered when prioritizing care. Additional information about nursing management will be included later in the chapter as it relates to speciic disorders.
might obtain others. In either instance the nurse should be familiar with how the tests are obtained, what they are used for, and normal versus abnormal results. This knowledge will also be necessary when providing child and family education related to the testing.
Nursing Diagnoses, Goals, Interventions, and Evaluation
Upon completion of a thorough assessment, the nurse might identify several nursing diagnoses, including:
• Fatigue
• Pain
• Impaired physical mobility
• Ineffective health maintenance
• Anxiety
• Ineffective family coping
TABLE 47.2 NORMAL DIFFERENTIAL FOR LEUKOCYTES (WHITE BLOOD CELL DIFFERENTIAL)
Age
Bands/
Stab (%)
Segs/Polys (%)
Eos (%)
Basos (%)
Lymphs (%)
Monos (%)
Birth–1 week 10–18 32–62 0–2 0–1 26–36 0–6
1–2 weeks 8–16 19–49 0–4 0 38–46 0–9
2–4 weeks 7–15 14–34 0–3 0 43–53 0–9
4–8 weeks 7–13 15–35 0–3 0–1 41–71 0–7
2–6 months 5–11 15–35 0–3 0–1 42–72 0–6
6 months–1 year 6–12 13–33 0–3 0 46–76 0–5
1–6 years 5–11 13–33 0–3 0 46–76 0–5
6–16 years 5–11 32–54 0–3 0–1 27–57 0–5
16–18 years 5–11 34–64 0–3 0–1 25–45 0–5
>18 years 3–6 50–62 0–3 0–1 25–40 3–7
Adapted from Fischbach, F. T. (2008). A manual of laboratory and diagnostic tests (8th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.
You have finished assessing Shaun and your findings include the following. The health history revealed he bled with all four of the teeth he has cut. Upon physical examination numerous bruises are noted. Based on the as- sessment findings, what would your top three nursing diagnoses be for Shaun?
Based on your top three nursing diagno- ses for Shaun, describe appropriate nursing interventions.
COMMON LABORATORY AND DIAGNOSTIC TESTS 47.1
Test Explanation Indications Nursing Implications
Blood type and cross-match
Determines ABO blood type as well as presence of antigens.
Cross-match is performed on RBC-containing products to avoid transfusion reaction
Trauma victim or any person in whom blood loss is suspected, in preparation for transfu- sion
Avoid hemolysis of specimen.
Appropriately sign and date speci- men. Apply “type and cross”
or “blood band” to child at the time of blood draw if indicated by the institution.
Most type and cross-match specimens expire after 48 to 72 hours.
Clotting studies Prothrombin time (PT), partial thromboplastin time (PTT), activated partial thromboplas- tin time (aPTT), international normalized ratio (INR)
Evaluation of common pathway in clotting mechanism
PT, INR: evaluation of extrinsic system PTT, aPTT: evaluation of
intrinsic system
Apply pressure to venipuncture site.
Assess for bleeding (gums, bruising, blood in urine or stool).
Coagulating factor concentration
Measures concentration of speciic coagulating factors in the blood
Hemophilia, DIC Apply pressure to venipuncture site.
Assess for bleeding (gums, bruis- ing, blood in urine or stool).
Deliver specimen to laboratory as soon as possible (unstable at room temperature).
Complete blood count (CBC) with differential
Evaluates hemoglobin and hematocrit, WBC count (particularly the percentage of individual WBCs), and platelet count
Anemia, infection, bleed- ing disorder, clotting disorder
Normal values vary according to age and gender.
WBC differential is helpful in evaluating source of infection.
May be affected by certain medications.
Hemoglobin elec- trophoresis
Measures percentage of normal and abnormal hemoglobin in the blood
Sickle cell anemia, thalassemia
Blood transfusions within the previous 12 weeks may alter test results.
Iron Evaluates iron metabolism Iron-deiciency anemia, hemosiderosis with chronic transfusion or hemoglobinopathies
Recent blood transfusions increase level.
Child should fast for 12 hours before the test.
Avoid hemolysis (will falsely elevate result).
Lead Measures level of lead in blood Lead poisoning Normal amount in blood is zero.
Reticulocyte count Measures the amount of reticu- locytes (immature RBCs) in the blood
Indicates bone marrow’s ability to respond to anemia with production of RBCs
Rises quickly in response to iron supplementation in the iron-deicient child.
Serum ferritin Measures the level of ferritin (the major iron storage protein) in the blood
Most sensitive test for determining iron- deiciency anemia
Elevated in hemolytic disease and if transfused recently.
Iron supplementation increases ferritin levels.
Adapted from Pagana, K. D., & Pagana, T. J. (2010). Mosby’s manual of diagnostic and laboratory tests (4th ed.). St. Louis, MO: Mosby.
NURSING CARE PLAN 47.1
Overview for the Child With a Hematologic Disorder
NURSING DIAGNOSIS: Fatigue related to decreased oxygen supply in the body as evidenced by lack of energy, increased sleep requirements, or decreased interest in play
Outcome Identification and Evaluation
Child will display increased endurance, desire to play without developing symptoms of exertion.
Intervention: Decreasing Fatigue
• Cluster nursing care activities and plan for periods of rest before and after exertion to decrease oxygen need and consumption.
• Encourage activity or ambulation per physician’s orders: early mobilization results in better outcomes.
• Observe child for signs of activity intolerance such as pallor, nausea, lightheadedness, or dizziness or changes in vital signs to determine level of tolerance.
• If child is on bed rest, perform range-of-motion exercises and frequent position changes: negative changes to the musculoskeletal system occur quickly with inactivity and immobility.
• Refer the child to physical therapy for exercise pre- scription to increase skeletal muscle
strength.
Outcome Identification and Evaluation
Child will be able to engage in activities within age parameters and limits of disease: child is able to move extremities, move about environment, and participate in exercise programs within limits of age and disease.
Interventions: Promoting Physical Mobility
• Encourage gross and ine motor activities as able within constraints of pain/bleed to facilitate motor development.
• Collaborate with physical therapy to strengthen muscles and promote mobility to facilitate motor development.
• Use passive and active range-of-motion (ROM) exercises and teach the child and fam- ily how to perform them to prevent contractures and facilitate joint mobility and muscle development (active ROM) to help increase mobility.
• Praise accomplishments and emphasize child’s abilities to improve self-esteem and encourage feelings of confidence and competence.
NURSING DIAGNOSIS: Impaired physical mobility related to pain from sickle cell crisis or acute bleeds or imposed activity restrictions, as evidenced by guarding of painful extremity, resistance to activity
NURSING DIAGNOSIS: Ineffective health maintenance related to knowledge and skill acquisition regarding nutritional and medical treatment of anemia, prevention of infection, home administration of intravenous clotting factors, or protection from injury as evidenced by new diagnosis and inability to verbalize appropriate treatment regimen or demonstrate medication administration skills
NURSING CARE PLAN 47.1
Overview for the Child With a Hematologic Disorder
(continued)Outcome Identification and Evaluation
Child’s health will be maintained: child will receive supplements, medications as prescribed and will eat an appropriate diet.
Intervention: Educating Parents About Effective Health Maintenance
• Educate the family about iron-rich foods to be promoted in the child with iron-deiciency anemia and limited in the child with thalassemia.
• Limit cow’s milk intake in the child with iron- deiciency anemia to decrease risk of microscopic gastrointestinal (GI) bleeding and increase appetite for other foods.
• Provide ongoing evaluation of nutritional intake to ensure that appropriate dietary restrictions are followed.
• Ensure that parents can verbalize understanding of home medication regimen: iron or folic acid
supplementation for anemia, prophylactic antibiot- ics for sickle cell anemia, chelation for thalassemia, and factor replacement for hemophilia.
• Have parents provide return demonstration of subcutaneous infusion of deferoxamine or intrave- nous factor as appropriate to ensure accuracy and independence in the home environment.
• Educate families about when to call or visit physician or nurse practitioner to ensure timely intervention when signs and symptoms develop.
NURSING DIAGNOSIS: Anxiety related to diagnostic testing as evidenced by parent verbalization, child resistance or crying with procedures
Outcome Identification and Evaluation
Child’s anxiety will be minimized: child will verbalize less fear, experience less pain with procedures.
Intervention: Relieving Anxiety
• Use topical anesthetic creams or agents for nonemergency laboratory draws to decrease stress related to needlesticks or venipunctures.
• Maintain a quiet and calm environment to reduce the child’s stress.
• Educate the child, as appropriate, and the family regarding the need for laboratory specimens to alleviate anxiety related to the unknown.
• Identify the need for the speciic test and explain the procedure before obtaining the specimen to decrease the anxiety and time required for the
procedure.
• Provide developmentally appropriate activities for the child: activities can reduce stress and also provide stimulus for children; serves as a model for the family.
(continued)
Anemia caused by the alteration or destruction of the RBCs is termed hemolytic anemia. There are several types of hemolytic anemia, such as sickle cell disease and thalassemia; these two disorders are discussed under the section on hemoglobinopathies.
Anemia related to insuficient intake of spe- ciic nutrients is the most common type of anemia in children. Nutrient intake may be reduced in children due to food dislikes or conditions that produce mal- absorption.
intake of the nutrients needed to produce the cells, alterations in the cell structure, or malfunctioning tissues (e.g., bone marrow). Anemia related to nutritional dei- ciency includes iron deiciency, folic acid deiciency, and pernicious anemia. Anemia may also result from toxin exposure (lead poisoning) or as an adverse reaction to a medication (aplastic anemia). Blood loss may result from surgery or trauma. Alteration or destruction of cells occurs in certain genetic and cellular development dis- orders (Bryant, 2010).
Overview for the Child With a Hematologic Disorder
(continued)NURSING CARE PLAN 47.1
Outcome Identification and Evaluation
Child will not experience hemorrhage: will experience decreased bruising or episodes of prolonged bleeding.
Intervention: Preventing Injury
• Assess for petechiae, purpura, bruising, or bleeding to provide baseline data for comparison; if present, may warrant intervention.
• Encourage quiet activities or play to avoid trauma with active play.
• Avoid rectal temperatures and examinations. Post sign at head of bed “no rectal temperatures or medications” to avoid rectal mucosa damage resulting in bleeding.
• Avoid intramuscular injections and lumbar punc- ture if possible to decrease risk of bleeding from a puncture site.
• If bone marrow aspiration must be performed, apply pressure dressing to site to prevent bleeding.
• Teach families about preferred physical activities for the child with idiopathic thrombocytopenia purpura (ITP) or hemophilia to provide safe physical activities and decrease risk for injury.
NURSING DIAGNOSIS: Risk for injury related to alteration in peripheral sensory perception, decreased platelet count, deicient coagulation factor, or excessive iron load
Outcome Identification and Evaluation
Child and/or family will demonstrate adequate coping skills, will verbalize feeling supported and demonstrate healthy family interactions.
Intervention: Promoting Effective Family Coping
• Provide emotional support to the child and family to improve coping abilities.
• Actively listen to the child’s and family’s concerns to validate their feelings and establish trust.
• Encourage parents to talk about their child and the illness to bring feelings out in the open.
• Validate feelings of guilt, shock, frustration, resent- ment, or depression to promote trust and begin appropriate coping.
• Provide open communication with the child and siblings: children appreciate honesty about their illness, and coping is improved.
• Refer families to community resources such as parent support groups and grief counseling to improve coping abilities.
• Encourage role-playing and play activities to identify the child’s fears and work through feelings.
NURSING DIAGNOSIS: Ineffective family coping related to hospitalization of child or chronic, pos- sibly life-threatening genetic disorder as evidenced by excessive tearfulness or denial statements, with- drawal, or verbalization of inadequate coping skills
dizziness, weakness, shortness of breath, pallor, and fatigue. Other symptoms may be subtle and dificult for the clinician to identify; these include dificulty feeding, pica, muscle weakness, or unsteady gait.
Explore the health history for risk factors such as:
• Maternal anemia during pregnancy
• Poorly controlled diabetes during pregnancy
• Prematurity, low birthweight, or multiple birth
• Cow’s milk consumption before 12 months of age
• Excessive cow’s milk consumption (greater than 24 ounces a day)
• Infant consumption of low-iron formula
• Lack of iron supplementation after age 6 months in breastfed infants
• Excessive weight gain
• Chronic infection or inlammation
• Chronic or acute blood loss
• Restricted diets
• Use of medication interfering with iron absorption, such as antacids
• Low socioeconomic status
• Recent immigration from a developing country (Borgna- Pignatti & Marsella, 2008; Bryant, 2010)
Evaluate the child’s diet for adequate intake of iron- rich foods. Recommended dietary daily intake for iron in children is:
• 0 to 6 months: 0.27 mg
• 6 to 12 months: 3 mg
• 1 to 3 years: 7 mg
• 4 to 8 years: 11 mg
• 9 to 13 years: 8 mg
• Boys 14 to 18 years: 11 mg
• Girls 14 to 18 years: 15 mg (Krebs, Primark, & Haemer, 2011)
Physical Examination
Observe the child for fatigue and lethargy. Inspect the skin, conjunctivae, oral mucosa, palms, and soles for pal- lor. Note spooning of the nails (concave shape) (Fig. 47.2).
Obtain a pulse oximeter reading. Evaluate the heart rate for tachycardia. Auscultate the heart for a low murmur.
Palpate the abdomen for splenomegaly.
Iron-Deficiency Anemia
Iron-deiciency anemia occurs when the body does not have enough iron to produce Hgb. In the United States, iron-deiciency anemia has a peak prevalence in children between the ages of 6 and 20 months, and again at the age of puberty (Borgna-Pignatti & Marsella, 2008). Cow’s milk consumption contributes to iron-deiciency anemia in older infants and young children due to its poor iron avail- ability (Bryant, 2010).
The heme portion of Hgb consists of iron surrounded by protoporphyrin. When not enough iron is available to the bone marrow, Hgb production is reduced. Adequate dietary intake of iron is required for the body to make enough Hgb. As Hgb levels decrease, the oxygen-carrying capacity of the blood is decreased, resulting in weakness and fatigue. In addition to delayed growth, iron-deiciency anemia has been associated with cognitive delays and behavioral changes.
Take Note!
For appropriate growth to occur in adolescence, increased amounts of iron must be consumed and absorbed.
Therapeutic Management
Iron supplements are usually provided in the form of ferrous sulfate or ferrous fumarate and are available over the counter. Dosage is based on the amount of elemental iron. The recommended amounts of elemental iron are:
• For prophylaxis: 1 to 2 mg/kg/day, up to a maximum of 15 mg elemental iron per day
• Mild to moderate iron deiciency: 3 mg/kg/day of el- emental iron in one or two divided doses
• Severe iron-deiciency anemia: 4 to 6 mg/kg/day of elemental iron in three divided doses (Borgna-Pignatti
& Marsella, 2008)
In more severe cases, blood transfusions may be indicated. Transfusion of packed red blood cells (PRBCs) is reserved for the most severe cases (Bryant, 2010).
When PRBC administration is warranted, follow speciic blood bank guidelines for administration. Monitor subse- quent laboratory results for improvement.
Nursing Assessment
For a full description of the assessment phase of the nursing process, refer to page 1707. Assessment indings pertinent to iron-deiciency anemia are discussed below.
Health History
Elicit a description of the current illness and chief com- plaint. Common signs and symptoms reported during the health history may include irritability, headache,
FIGURE 47.2 Note the concave shape of nails
(“spooning”) that occurs with iron-deiciency anemia.
Take Note!
Parents are often concerned that a diagnosis of iron-deficiency anemia or referral to the WIC pro- gram may lead to interventions from children’s services.
Assure the family that as long as appropriate measures are taken to address the anemia, referrals of this nature are not generally made.
Teaching About Iron Supplement Administration
The use of iron supplements in infants begins with the use of formula fortiied with iron in the formula-fed infant. Oral supplements may also be necessary if the baby’s iron levels are extremely low. Oral supplements or multivitamin formulas that contain iron are often dark in color because the iron is pigmented. Teach parents to precisely measure the amount of iron to be administered.
Parents should place the liquid behind the teeth, as iron in liquid form can stain the teeth. Iron supplementation can also cause constipation. In some cases reducing the amount of iron can resolve this problem, but stool soft- eners may be necessary to control painful or dificult-to- pass stools. Encourage parents to increase their child’s luid intake and include adequate dietary iber to avoid constipation.
Take Note!
Teach parents to keep iron-containing supple- ments out of the reach of young children in order to prevent accidental ingestion leading to overdose or poisoning.
Laboratory and Diagnostic Tests
Laboratory evaluation will reveal decreased Hgb and Hct, decreased reticulocyte count, microcytosis, hypo- chromia, decreased serum iron and ferritin levels, and an increased free erythrocyte protoporphyrin (FEP) level.
Nursing Management
Nursing management of the child with iron deiciency focuses on promoting safety, ensuring adequate iron intake, and educating the family.
Promoting Safety
The child with anemia is at risk for changes in neuro- logic functioning related to the decreased oxygen supply to the brain. This can lead to fatigue and inability to eat enough. Neurologic effects may be manifested when the child’s ability to sit, stand, or walk is impaired. Provide close observation of the anemic child. Assist the older child with ambulation. Educate the parents on how to protect the child from injury due to an unsteady gait or dizziness.
Providing Dietary Interventions
Ensure that iron-deicient infants are fed only formulas fortiied with iron. Interventions for breastfed infants include beginning iron supplementation around the age of 4 or 5 months. Iron supplementation may range from adding iron-fortiied cereals to the child’s diet to giving iron-containing drops. Encourage breastfeed- ing mothers to increase their dietary intake of iron or take iron supplements when breastfeeding so that the iron may be passed on to the infant. For children over 1 year of age, limit cow’s milk intake to 24 ounces per day. Limit fast-food consumption and encourage intake of iron-rich foods such as red meats (iron from red meat is the easiest for the body to absorb), tuna, salmon, eggs, tofu, enriched grains, dried beans and peas, dried fruits, leafy green vegetables, and iron- fortiied breakfast cereals.
Teach the parents about dietary intake of iron.
Encourage parents to provide a variety of foods for iron support and vitamins and other minerals nec- essary for growth. A big problem for toddlers is their picky eating. This often becomes a means of control for the child, and parents should guard against get- ting involved in a power struggle with their child.
Referring parents to a developmental specialist who can assist them in their approach to diet may prove beneicial. Refer families who meet the inancial limits and who have children age 5 and younger to the Women, Infants, and Children (WIC) program, which provides for supplementation of infants’ and children’s diets.
H E A LT H Y P E O P L E 2020
Objective Nursing Significance Reduce iron deiciency
among young children and females of child- bearing age.
• Encourage use of iron- fortiied formulas and infant cereal.
• Encourage iron supple- mentation in the second half of infancy for the breast-fed infant.
• Educate parents about iron-containing foods.
• Encourage adolescent females to consume a diet high in iron-rich foods.
Healthy People Objectives based on data from http://www .healthypeople.gov.