Heidi Heffelfinger, SN

Contra Costa College

March 8, 2011
KOMC – Pediatrics
Trich Overbo & Nancy Maia

PEDIATRIC NURSING PROCESS RECORD

Patient’s Initials: A.T. Room Number: 1009BAge: 14 mon. Sex: F Dates of Care: 03/05 – 03/06/2011
Allergies: NKA Height & Weight Percentile: Wt – 20th percentile (9.34kg); Ht – 43rd percentile (75.5cm)
Date of Admission: 03/04/2011 Diagnosis: Cancer: Neuroblastoma, Stage III, Intermediate Risk
Other Health Problems: Formula intolerance; in-utero meth., THC, & tobacco exposure; renal insufficiency
Treatments: Surgery (02/24/2011) – partial resection of pelvic tumor (with gross residual) and placement of ureter
stent, Broviac placement (03/04/2008) – for chemotherapeutic treatments and blood draws. IV therapy of
chemotherapeutic agents and fluids. Prophylactic antibiotic treatment.
Pathophysiology: Neuroblastoma is an extracranial, hemorrhagic, solid tumor arising along the sympathetic
nervous system chain from neurocrest cells, often amid the adrenal medulla and paraganaglia and
cervical/thoracic chains. Neuroblastoma is the most frequently diagnosed solid tumor cancer in childhood and
the most common cancer diagnosed in infancy and in utero. The most common site for primary tumor
development is in the abdomen. Prognosis for neuroblastoma is often poor due to the invasiveness of the
tumor, early and wide metastasis to lymph nodes, liver, lungs, and bone, and diagnosis not usually occurring
until after the tumor has metastasized. The vast majority of neuroblastoma tumors secrete catecholamines.
Neuroblastoma is staged into low, average, and high-risk groups with assignment of risk based on tumor cell
differentiation and histology. Low-risk patients often only require resection surgery and minimal to no
chemotherapy and radiation. Intermediate-risk patients require resection and chemotherapy and may have
radiation treatment as well. High-risk patients require resection, chemotherapy and radiation. Six stages are
also recognized: Stage I – localized primary tumor easily resected; Stage IIA – localized primary tumor with
incomplete resection; Stage IIB – localized primary tumor with incomplete resection and lymph involvement;
Stage III – unresectable infiltrating across the midline; Stage IV – metastatic to lymph, bone, liver, skin and
other organs; Stage IV-S – metastatic with no bone involvement. Although neuroblastoma often has a poor
prognosis it is unique in that spontaneous regression does occur with tumor maturation and formation of a
benign ganglioneuroma, but so do relapses often occur later in childhood. Prognosis is good when diagnosed
before metastasis and treated with radical surgery, chemotherapy, irradiation, and biologic (retinoid
supplementation and bone marrow transplantation).
Signs & Symptoms: Enlarged abdomen, constipation, anorexia, and/or urinary retention caused by growing
abdominal tumor mass presing on abdominal muscles and skin and/or compressing gastrointestinal organs
and/or genitourinary organs. Pain, weakness, neurological changes, difficulty sleeping, and irritability
occurring from tumors pressing on nerves. Orbital ecchymosis, proptosis, or nystagmus due to tumors
developing peri-orbital. Urinalysis will show catecholamines and/or their metabolites as neuroblastomas
secrete catecholamines. Fever, malaise, and leukocytosis due to immunologic system activity. Often
patients with early localized tumors are asymptomatic.
Etiology: Research has not been able to identify the actual etiology of neuroblastoma tumors. No
environmental, maternal, or paternal exposures have been identified. Neuroblastoma malignancies have
been identified as arising from symphoblastoma embryological lines of sympathetic nervous system
neuroblastic cells. It should be noted that 1 to 2% of neuroblastoma patients have a family history of the
disease.
Common Complications: Cord compression from paraspinal tumor, tumor lysis syndrome, hypertension or
renal insufficiency from adrenal involvement and/or organ compression.
Presenting Signs and Symptoms: A.T. presented with gastrointestinal and genitourinary disturbances including
constipation and urinary retention three months prior to diagnosis. Laboratory findings indicated presence of
catecholamines and metabolites in urine, mild anemia, and leukocytosis.

Physical Assessment
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Appearance on First Sight: Active, playful toddler, smiling and interacting with mother.
Patient’s/Guardian's Understanding of Illness: Foster mother receptive of education regarding illness. She
has a full grasp of treatments necessary and long-term prognosis. She is actively seeking and engaging in the
necessary learning process.
Respiratory Function: Lungs clear in all lobes bilaterally. R-24. SpO2 100% RA. Sporatic, strong non-productive
cough, recovering from recent laryngotracheobronchitis (Croup) infection.
Cardiovascular Function: S1, S2 audible, AP 140 regular, BP: 109/62 (RL, sitting), cap refill 1 sec., no signs of
edema, good skin turgor,
Sensory Function: A.T. Is receptive to touch on all areas of skin with particular sensitivity noted over broviac site
and ventral surface of both feet.
Neurological Function: Alert & oriented – responds to own name and understands names of objects, and food
items; clapped when asked, “high-fived” both hands, able to freely move head in all direction. PERRLA. Equal
& strong bilateral grips, no unilateral deficit in lower extremities.
Rest, Sleep, and Comfort: Mother states A.T. has had inadequate sleep during hospital stay related to irritation
of broviac site, some nausea, and disturbances due to nursing care
Condition of Skin, Hair, Mouth, and Nails: Healthy, clean hair. Nails, clean well-trimmed on hands and feet.
Skin well-hydrated, smooth. Small 2 cm round ecchymotic area on left cheek due to ambulation fall. Bilateral
sets of small puncture marks on medial sacral skin from previous bone marrow aspiration. 2 cm circular red
scarring on left mid-clavicle skin from broviac-placement surgery. Erythema, rash and pruritis peri-broviac
dressing.
Musculoskeletal: Musculoskeletal function is normal.
Ability to Care for Self: Toddler, requires family assistance. Family actively participates in all care.
CSM of Extremities: Good cap refill in all extremities. Equal and bilateral brachial and pedal pulses.
Sensation equal in all extremities. Pt able to freely move all extremities.
Condition of Dressings/Wounds: Single-lumen Broviac at left chest, mid-clavicular line superior to nipple.
Dressing is clean,dry, and intact. Free from edema. Erythema and rash located around entire dressing site.
A.T. is frequently patting at chest and pulling at broviac line.
Condition of Tubes and Equipment: All IV tubes, bags, and monitoring equipment functioning properly.
Vital Signs: Temp: 97.9°F HR: 140 RR: 24 BP: 109/62 Intake: 845 mL Output: 625 mL
Diet: regular, finger foods Date of last BM: 03/06/2011 Fluids: D5¼NS, D5½NS, & NS infusing dependent
upon chemotherapeutic regimen. Minimum of 10mL/hr D5¼NS maintained.
Genitourinary Function: Patient's urinary function is normal, with average of 6 wet diapers/day per mother.
Some compliance issues with family saving diapers for weight.
Emesis: One bout on 03/05/2011 @ ~2245 due to late administration of Zofran. Family denies any other emesis.
Gastrointestinal Function: Patient is having constipation with one or two small 1 to 2 cm hard stool fragments
passed once to twice daily.
Complaints: Family denies any complaints at this time.
Environment/Safety: lEmergency medication sheet at bedside, weight taken daily for updating of sheet. Suction,
O2 and BVM devices located at bedside. While in crib, rails are up x2 and plastic barriers down x2. Floor clear
and dry. Call light and phone within mother's reach. 24 hour family monitoring of A.T. Activity ad lib as able with
IV connection. Automatic HR, spO2, B/P, and RR monitoring during chemotherapy.

H. Heffelfinger, SN CCC
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Medications (see drug cards pages 9 – 13)

Scheduled Medications:
DRUG CLASS
DRUG/DOSE/ROUTE/FREQUENCY REASON
(therapeutic / pharmacological)
sulfamethaxole/trimethoprim (Septra) 24 mg(1) Anti-infectives / Antiprotozoals Prophylactic for pneumocystic
oral solution BID q F/Sa/Su pneumonia
chlorhexidine gluconate (Peridex) 0.12% 5 Anti-infectives / Antimicrobials Prevent oral ulcers
mL oral rinse TID Prevent constipation
hydrocortisone (Hytone) 1% cream applied Anti-inflammatories / Corticosteroids Reduce localized rash & urticaria
AA BID
ondanestron (Zofran) 1.35 mg(2) IV push q8h Antiemetics / 5 HT3 Antagonists Prevent/Treat nausea/vomiting
heparin (Hep-Lok) 30 Units(3) IV push q8h Anticoagulants / Antithrombolytics Prevent clotting in IV line
carboplatin (Paraplatin) 167 mg(4) over 60 min Antineoplastics / Alkylating Agents Destruction of malignancies
IVPB every day x3 days
etoposide (Vepesid) 36 mg(5) over 60 min Antineoplastics / Podophyllotoxins Destruction of malignancies
IVPB every day x3 days
polyethylene glycol (Miralax) 3.7 g(6) PO BID Laxatives / Osmotic Laxatives Constipation
(1) Safe dose for 9.34 kg child with renal insufficiency is 18.7 – 28.05 mg/dose
(2) Safe dose for 9.34 kg child is 1.4 mg/dose
(3) Safe dose for 9.34 kg is 10 Units/mL/flush; enough to fill lock-set
(4-5) Dose and schedule depend on protocol and patient response
(6) Normal dosing for child >6 mon. is 0.4 g/dose: Dose appears to be high

As Needed (PRN) Medications:

DRUG CLASS
DRUG/DOSE/ROUTE/FREQUENCY REASON
(therapeutic / pharmacological)
acetaminophen (Tylenol) 140 mg(1) oral drops Antipyretics, Analgesics Mild pain (1-3/10)
q4h
diphenhydramine (Benadryl) 9 mg(2) IV push Antihistamines, Antiemetics / H1 Antagonists Nausea, urticaria, hives, rash
q6h
(1) Safe dose for 9.34 kg child is 93.4 – 140.1 mg/dose, NTE 5 doses/day
(2) Safe dose for 9.34 kg child is up to 11.68 mg/dose, NTE 300 mg/day

Psychosocial Assessment
Culture and Its Implications for Care: Caucasian appearing female of mixed African-American and Caucasian
heritage. Biological mother is Caucasian while biological father is of mixed African-American and Caucasian
heritage. Foster family, who is intending on adoption, is African-Amerian (AA). In AA families, the extended
family structure is important for teaching health strategies and providing support. Women are extremely
important with regard to health-care decision making and the dissemination of health information.
How Do You Feel About Caring for this Patient? I really enjoyed caring for this patient and her family, although
I found it to be an emotional experience due to the emotional implications of childhood cancer, cancer of the
primary caregiver, and a child who is a ward of the state.
Describe Parent-Child Interaction: Child and mother interaction was appropriate. Frequent holding, rocking,
and caressing of child was observed. Appropriate play such as “Peek-A-Boo”, “Itsy-Bitsy Spider”, and similar
was observed frequently. Mother was seen reading to child. Reassuring words and touches were given during
medical interventions and normal nursing care.
How Did You Include Play Therapy in this Child’s Nursing Care? Although this child is too young to
understand that she is ill, I did include playing with her with gloves on and playing with gloves (tossing up in the
air) to help alleviate her fears of gloved caregivers.
Developmental Assessment: Use Erickson’s Stages
Ethical Issues: lThe foster mother, a paternal cousin, wants to adopt the child, but is herself undergoing
chemotherapy for late stage, metastatic breast cancer. I could help but have in mind her long term prognosis
H. Heffelfinger, SN CCC
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and if she would be the best choice for permanent guardian. However, this did not affect my care in any
manner.
Spiritual Practices: A.T.'s family is Baptist. The family pastor came to visit on Sunday, 03/06/2011, and stayed for
well over an hour. He spoke to me of the importance for prayer and to give up all worries and concerns to God
as he would ensure the proper outcome. Both A.T.'s mother and the pastor explained to me how A.T. coming
into the mother's life was a god-given grace to heal both A.T. and the mom. The family regularly attends church
services and is active in many church activities.
Patient History: A.T. presented in November, 2010 with severe constipation and urinary retention requiring
intermittent catheterization. On 02/01/2011, an MRI found a pelvic mass presacral in location. A resection was
performed, as well as a urethral stent placement, on 02/08 however gross residual remained. Pathology
determined the mass to be intermediate risk, Stage 3 neuroblastoma. A.T. is a ward of the state born to a
mother abusing methamphetamines, THC, and tobacco. A.T. suffered in utero hypoxia due to a maternal
seizure during epidural placement pre-cesarean section. A.T.’s foster mother is a cousin and is herself
undergoing treatment for metastatic breast cancer. A.T. no longer needs urinary catheterization due to stent
placement. She is hospitalized at this time for broviac placement and her first round of chemotherapy.

Lab Data
DATE TEST DEFINITION NORMALS PATIENT’S REASON
(KOMC values) DATA (see index)
03/04/2011 Aspartate Aminotransferase (AST) Measure of AST enzyme in blood (liver function) 34-110 U/L 27 U/L ↓ (1)
Total Bilirubin (TBILI) Amount of bilirubin in blood (direct & indirect) 0.1-1.1 mg/dL < 0.1 mg/dL ↓ (1)
White Blood Cell Count (WBC) Amount of WBCs per microliter of blood sample 6-17 K/μL 25.1 K/μL ↑ (2)
Red Blood Cell Count (RBC) Amount of RBCs per microliter of blood sample 4-5.2 M/μL 3.74 M/μL ↓ (3)
Hematocrit (HCT) % of volume of blood made of red blood cells 33-39% 32.1% ↓ (3)
Absolute Neutrophil Count (ANC) Amount & size of thrombocytes in blood sample 1.6-8.6 K/μL 11.9 K/μL ↑ (2)
03/05/2010 Blood Calcium (Ca++) Amount of Ca++ in blood sample 8.4-10.2 mg/dL 10.4 mg/dL ↑ (1)
Urinalysis (UA) Multiple tests on urine specimen negative positive ↑ (4)
red blood cells Amount of red blood cells and casts in urine 0-3/HPF 6/HPF ↑ (4)
squamous cell sediments Amount of microscopic epithelial cells in urine 0-5/LPF 7/LPF ↑ (4)
03/06/2011 Blood Sodium (Na+) Amount of Na+ in blood sample 137-145 mEq/L 136 mEq/L ↓ (5)
RBC 4-5.2 M/μL 3.76 M/μL ↓
Blood Carbon Dioxide (CO2) Measure of CO2 in blood sample 20-24 mEq/L 25 mEq/L ↑ (6)
HCT 33-39% 32.3% ↓
Anisocytosis Presence of red blood cells of unequal sizes negative 1+ ↑ (3)
Poikilocytosis Presence of red blood cells of differing shapes negative 1+ ↑ (3)

Reasons Index: (1) Indicative of hepatic insufficiency likely due to liver compression from abdominal tumor. (2)
Related to immune system reaction to malignancy. (3) Anemia which could be resultant of poor nutritional status or
systemic effects of malignancy. (4) Suggestive of glomerulonephritis related to A.T.'s renal insufficiency. (5)
Decrease due to increased sodium loss – in A.T. likely related to renal insufficiency. (6) Increase due to minor
hypercapnea possibly result of hospitalization stress, or just a test anomaly.

Diagnostic Studies: None perfomed during current hospitalization.

Nursing Diagnoses:

1) Risk for Infection related to disruption in vascular continuity (Broviac placement) and effects & side effects of
chemotherapeutic agents.

2) Deficient Knowledge (Parental) related to Broviac and chemotherapy regimen.

3) Imbalanced Nutrition (Less than Body Requirements) related to increased metabolic rate, insufficient nutrients
available for normal cells due to malignancy, anorexia due to malignancy and chemotherapy, and nausea and
vomiting due to chemotherapy.

4) Activity Intolerance related to decreased oxygenation to tissues secondary to low hemoglobin.

5) Acute Pain related to treatments, procedures, and medication side effects.

H. Heffelfinger, SN CCC

NURSING
DIAGNOSIS
1) Risk for infection related
to disruption in vascular
continuity and effects &
side effects of
chemotherapeutic agents
GOAL
Knowledge of Infection
Control: By 03/05/2011 2100,
A.T.'s family will verbalize
understanding of need for
infection control, ways of
preventing infections, and need b) Infection Protection: Teach patient's b) Hand-washing is the most
to teach and inform others in
contact with the patient.
INTERVENTION –
NURSING ORDERS
a) Infection Protection: Monitor vital a) Changing vital signs and lab
signs and lab values.
family the importance of frequent
hand washing and cleanliness.
c) Infection Protection: Keep patient,
linen, and surrounding area(s)
clean.
d) Infection Protection: Encourage
fluid intake.
e) Infection Protection: Administer
anti-microbial medications.
Nursing Process Record / Page 5
RATIONALE EVALUATION
Goal/outcome only partially met.
values are often the first clinical Patient and family did self-direct
sign that an infection has taken towards hand-washing, however
hold needed occasional reminders to
inform new visitors to do the same.
Pt's family twice seen handing
effective means of infection bottle back to Pt after it dropped
protection. onto floor. Family receptive to
education, but needs more
c) Each client has a right to expect a reinforcement.
clean environment. Maintaining
cleanliness of patient and
environment will decrease number
of infectious agents patient will
come into contact with.
d) Fluids promote diluted urine and
frequent emptying of bladder;
reducing stasis of urine, in turn,
reduces risk of bladder infection
or urinary tract infection (UTI).
e) Anti-microbial agents are either
toxic to pathogens or retard
pathogenic growth.
H. Heffelfinger, SN CCC

NURSING GOAL
DIAGNOSIS
2) Deficient Knowledge Information Processing: By
(Parental) related to 03/06/2011 2100, A.T.'s family
Broviac and will demonstrates motivation to
chemotherapy regimen. learn, identify perceived
learning needs, and verbalize
understanding of desired
content.
INTERVENTION –
NURSING ORDERS
a) Learning Facilitation: Question
parent regarding previous
experience and health teaching.
b) Learning Facilitation: Determine
patient or caregiver’s self-efficacy
to learn and apply new knowledge.
c) Learning Facilitation: Encourage
repetition of information or new
skill.
d) Learning Facilitation: Provide a
quiet atmosphere without
interruption.
e) Learning Facilitation: Explore
attitudes and feelings about
changes.
Nursing Process Record / Page 6
RATIONALE EVALUATION
a) Adults bring many life experiences Goal/outcome met. Patient and
to each learning session. Adults family practiced skills to care for
learn best when teaching builds on child. Multiple learning sessions
previous knowledge or with 4 different facilitators to learn
experience. skills. Family not yet proficient in
skills, but verbalize full
b) Self-efficacy refers to one’s understanding of skills needed.
confidence in his or her ability to
perform a behavior. A first step in
teaching may be to foster
increased self-efficacy in the
learner’s ability to learn the
desired information or skills.
c) Repetition assists in learning and
retention of information as well as
builds confidence.
d) Quiet, interruption-free
atmosphere allows for greater
concentration.
e) This assists the nurse in
understanding how learner may
respond to the information and
possibly how successful the
patient may be with the expected
changes.
H. Heffelfinger, SN CCC
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NURSING GOAL INTERVENTION – RATIONALE EVALUATION

DIAGNOSIS NURSING ORDERS

3) Imbalanced Nutrition Nutritional Status – Nutrient a) Nutrition Monitoring: Assess and a) Maintaining or gaining weight Goal/outcome not met. A.T. was
(Less than Body Intake: By 03/06/2011 2100, document weight daily. over the short term is indicative of 9.335 kg at beginning of shift on
Requirements) related to A.T. will not have lost any good nutritional status. 3/5/11 and 9.224 kg at end of shift
increased metabolic rate, additional weight. on 3/6/11.
insufficient nutrients b) Nutrition Therapy: Encourage b) Toddlers can have picky appetites,
available for normal cells family to bring food from home as more familiar foods may
due to malignancy, appropriate. encourage greater consumption.
anorexia due to
malignancy and c) Nutrition Therapy: Provide c) Attention to the social aspects of
chemotherapy, and companionship during mealtime. eating is important in both the
nausea and vomiting due hospital and home setting.
to chemotherapy.
d) Nutrition Monitoring: Monitor d) Serum albumin - indicates degree
laboratory values that indicate of protein depletion; transferrin is
nutritional well-being/deterioration. important for iron transfer and
typically decreases as serum
protein decreases; RBC & WBC
counts are usually decreased in
malnutrition, indicating anemia
and decreased resistance to
infection; potassium is typically
increased and sodium is typically
decreased in malnutrition.

e) Nutrition Monitoring: Determine e) Proper assessment guides

etiological factors for reduced intervention. For example,
nutritional intake. patients teething may require
softer foods.

H. Heffelfinger, SN CCC
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Bibliography:
Ackley, B. J. & Ladwig, G. B. (2009). Pediatric Nursing Care Plans for the Hospitalized Child (3rd ed.). Upper Saddle River,
NJ: Pearson Prentice Hall.

Axton, S. & Fugate, T. (2008). Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care (8th ed.). St. Louis,
MO: Mosby Elsevier.

Deglin, J. H. & Vallerand, A. H. (Eds.). (2007). Davis’s Drug Guide for Nurses (11th ed.). Philadelphia, PA: F. A. Davis.

Eckman, M. & Labus, D. (Eds.) (2010). Fluids & Electrolytes: an Incredibly Easy Pocket Guide (2nd ed.). Philadelphia, PA:
Wolters Kluwer/Lippincot Williams & Wilkins.

Hockenberry, M. J., & Wilson, D. (2011). Wong's Nursing Care of Infants and Children (9th ed.). St. Louis, MO: Mosby
Elsevier.

Myers, T. (Ed.). (2009). Mosby’s Dictionary of Medicine, Nursing, & Health Professions (8th ed.). St. Louis, MO: Mosby
Elsevier.

Pagana, K. D. & Pagana, T. J., (2006). Mosby’s Manual of Diagnostic and Laboratory Tests (3rd ed.). St. Louis, MO: Mosby
Elsevier.

Venes, D. (Ed.). (2001). Taber’s Cyclopedic Medical Dictionary (20th ed.). Philadelphia, PA: F. A. Davis.

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Drug Cards – Scheduled Medications

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Drug Cards – PRN Medications

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