NURSING CARE OF A CHILD WITH HEMATOLOGIC DISORDER PEDIA LEC

Ma’am Jaclyn Charmaine J. Magpantay, RN, MAN

BLEEDING DISORDERS
ANATOMY & PHYSIOLOGY REVIEW
Platelets
● responsible in creating a seal when blood vessels are damaged
○ Damaged blood vessels → send signals to the
bloodstream → attract the platelets to go there →
create a seal
Clotting Factors
● Important to make sure that the seal created by platelets would
be stable and not dislodged
● Proteins present in the bloodstream that would prevent the
platelet plug to be dislodged, therefore, the bleeding that would
occur in our patient would be controlled or would be stopped
● Involved in bleeding disorders; different from platelets
● Without these clotting factors (such as in hemophilia) there would
be a problem with the controlling of bleeding
■ If one is affected then the other one will
compensate.
■ Ex. Even though we have a decrease of factor 8
that amount is sufficient to control the bleeding or
to finish or complete the entire coagulation
cascade
● Hereditary bleeding disorder that result from deficiency of specific
clotting factors
● Hemophilia A aka Factor VIII is most common type (and most severe)
○ The missing/deficient clotting factor is Factor 8
○ Also known as Classic hemophilia
○ 80% of people with hemophilia

Coagulation Cascade
● Series of steps that are activated so that there will be stabilization
of the platelet plug
● When there is damage to blood vessels → chemical signals sent
by the bloodstream → first clotting factor that would be activated
is the factor 12. Like lock and key mechanism that would activate TYPES OF HEMOPHILIA
the factor 11 → factor 9 → factor 8 → factor 10 → factor 5 →
A B C
thrombin → fibrinogen
○ The fibrinogen, when it is divided into several It is the most common It is the second most It is a mild form of
components, it becomes fibrin type of hemophilia common type of hemophilia
○ Fibrin is responsible for making the platelet plug stable (severe) hemophilia (moderate) (mild)
(added layer of security for our platelet plug)
● If one of the clotting factors would decrease or would be missing X-linked recessive X-linked recessive Autosomal recessive
on the cascade then there is no fibrin that would result in that disorder (only males will disorder (only males disorder (need 2 copies
cascade. manifest s/sx) will manifest s/sx) of the gene for disorder
○ Sometimes, on the thrombin level, it would already to manifest; affects both
stop → nothing will make that plug stable causing the males & females)
uncontrollable bleeding in hemophilia It is also known as It was originally named Deficiency of factor XI
factor VIII deficiency or “Christmas disease”.
classic hemophilia Caused by factor IX
deficiency
80% of the cases would
be the classic The first person to have
hemophilia this disease is Stephen
Christmas → christmas
disease

NOTE: All types would have the same manifestations

Hemophilia
CLINICAL MANIFESTATIONS
● Has a missing clotting factor depending on the type of hemophilia
● Children usually do not manifest s/sx until after 6 months of age (begin
● X-linked recessive disorder
moving around, losing teeth)
○ X chromosome would be affected that would contain the
○ Because at 6 months of age, the child begins to crawl, walk,
mutated gene → only the males will have the manifestation
climb stairs
of the disease while the females are the carrier
■ Ex. in crawling, the knees are stressed → easy
○ Only males would have manifestations because they only
bruising on the knees.
have one X chromosome (same with baldness because it is
■ Ex. mild bump of the elbow on the table → easy
also x-linked recessive disorder)
bruising on the elbow or sometimes swelling
■ Has a significant decrease of clotting factors that
● Spontaneous bleeding
would affect the coagulation cascade resulting to
uncontrollable bleeding ○ In some countries or even in the PH, early circumcision is
○ Females are more of a carrier because they have 2 X being practiced. So as soon as the baby boy is born →
chromosomes

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NURSING CARE OF A CHILD WITH HEMATOLOGIC DISORDER
Ma’am Jaclyn Charmaine J. Magpantay, RN, MAN
circumcision → too much bleeding on the circumcised part →
prompt the report to the primary caregiver
○ Ex. simple activities like brushing of the teeth that would
also result to uncontrollable bleeding of the gums
■ Bleeding will stop temporarily and it would bleed
profusely again
● Hemarthrosis (bleeding into joint space)
○ Mostly the hinge joints
■ Elbows, knees, ankles
■ These hinge joints has a soft spots and not that
protected on the sides
■ If it swells → bleeding go to the synovial fluid →
swelling → painful
● Deep tissue hemorrhage
○ That would involve the joints and muscle
○ Life threatening situation
○ Affects the brain → bleeding in the brain, in the neck that
would compromise the airway
● Nosebleeds (Epistaxis)
○ But not severe compared to other bleeding disorders)
● Easy bruising (ecchymosis)
○ There would be dark purplish marks on the body that would
not go away
○ Sign of bleeding that would alarm the parent & should be
reported to healthcare practitioners
● Hematuria
○ Fresh blood in the urine
○ Or Hematochezia - fresh blood in the stool
● Life-threatening bleeding includes:
○ Head/intracranial
■ Internal bleeding
○ Neck and throat
■ Bleeding in neck compromises the airway
■ Considered as an emergency
○ Abdominal/GI
■ Evidenced by hematochezia
○ Iliopsoas muscle with decreased hip ROM
■ Illopsoas muscle connects the femur to the lesser
trochanter
■ The pain would be at the hip area → decreased
movement or range of motion of the hips
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NOTE: Life threatening because it is painful and these are major organs (like
the brain & neck) that’s why when this happens, the patient really need to do
recombinant factor infusion (mainstay treatment for patient with hemophilia)
TREATMENT
● PRICES
○ Protection - protect the affected area from further injury
○ Rest - apply splint to immobilize the area or bandage
■ NEVER a cast as it may cause bruising because of
its tightness and we may not be able to see
what’s happening under it
○ Ice - to promote vasoconstriction that would further prevent
the bleeding episode
■ Should only be done under 15 mins because
longer periods may cause a rebound effect of cold
therapy (vasodilation)
■ Book: 5 minutes ice, 10 minutes rest, 5 minutes
ice, 10 minutes rest, and so on
○ Compression - could be manual compression to stop the
bleeding
○ Elevate - above the level of the heart to decrease the
pressure → decrease bleeding
○ Support - ex. when you elevate the arm/legs, you may put a
pillow underneath to make the patient comfortable
● Corticosteroids and NSAIDs
○ Corticosteroids decrease the swelling or inflammation
especially if there is already hemarthrosis
○ NSAIDs are actually contraindicated as these may affect the
coagulation cascade but there is no choice but to control the
pain
○ Do NOT give aspirin because it is an anticoagulant
○ Goal to control bleeding by replacing the missing clotting
factor and prevent complications
● Factor Replacement Therapy
○ Depends on the type
○ Ex. Hemophilia A - recombinant factor VIII will be replaced
○ Not a blood transfusion; similar to the usual IV medication
○ Powder form reconstituted with a diluent and infused to the
patient
○ Patients may infuse the medication themselves at home as
this is a lifelong disorder
○ Nursing Responsibility: Teach them how to administer their
medications at home to lessen the hospitalization
○ But for toddlers and preschoolers, some moms are hesitant
to do this that’s why they still go on an outpatient basis for
this recombinant factor
○ 2 Therapies involved in factor replacement:
a. On demand
■ Ex. the patient is already bleeding then we
have to give the recombinant factor ASAP
b. Prophylaxis
■ Preventing further occurrence of massive
bleeding
■ Scheduled infusions of factor 2-3 times/week
○ It depends on the case of the patient whether we are going
to give on demand (ASAP/STAT) or prophylaxis (lifelong
treatment or there is already a time frame when we are
going to give it for example 2-3x a week)
NURSING CARE OF A CHILD WITH HEMATOLOGIC DISORDER
Ma’am Jaclyn Charmaine J. Magpantay, RN, MAN
● IV infusions consist of:
○ Fresh frozen plasma
■ Infusion of choice for traumatic injury that
would result to massive bleeding
○ Cryoprecipitate
■ According to Ma’am’s research, it is the last
resort because of the certain issues and
concern that would result to cryoprecipitate
○ NOTE: The difference of fresh frozen plasma
cryoprecipitate is we thaw the fresh frozen plasma to about
40ºC before we administer it to the patient.
● DDAVP (Desmopressin acetate)
○ Deamino D-arginine Vasopressin
○ An analog of vasopressin, causes a 2-4 fold increase in factor
VIII
○ Stimulate the endothelial factors to release factor VIII in the
bloodstream
○ Given intranasally (nasal spray) so that it would stimulate
the release of factor VIII from the endothelial cells
○ To deliver the nasal spray:
1. Position of the patient should be upright and not
lying
2. Perform nasal care first to make sure that nose is
clean (blow the nose, check if there is any
obstruction)
3. If spray is used for the first time, do a test spray
away from the patient and if you noticed that there is
some medication released from the nasal spray
bottle then you can use it already
4. If you are going to deliver 2 sprays per nostril, wait
for 30-60 seconds before delivering the next nasal
spray
5. Make sure to occlude the opposite nostril or one
nostril before delivering the medication
○ NOTE: Do not interchange the one that is being used for the
treatment of nocturnal enuresis and diabetes insipidus
because it is different although it is also DDAVP
● Amicar (epsilon aminocaproic acid)
○ the problem with frequent clotting factor treatment
(recombinant or infusion), because it is extraneous (foreign &
lab-made; not natural to the body to have them) → the body
would eventually create antibodies against it. That antibody
is known to be inhibitors.
○ A complication of this treatment is called inhibitor
development and if that would happen, the recombinant
factor would be ineffective → Amicar is given
○ Can be given orally (liquid or tablet form) or intravenously
(IV) if the patient is hospitalized to have a faster result
COMPLICATIONS OF TREATMENT
● Inhibitor/antibody development
○ Amicar is given to be part of the treatment instead of the
recombinant factor
● Blood-borne illnesses
○ Because of massive bleeding, patient may be receiving blood
components or blood product → blood-borne illness
○ Hep B and C
○ HIV
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NURSING CONSIDERATIONS
● Factor replacement given on time
○ There is a certain schedule to give it
○ But for emergency cases, give it ASAP to prevent
complications of bleeding in patient with hemophilia
● Lab monitoring as ordered
○ Best laboratory test for hemophilia is PTT (partial
thromboplastin time) or aPTT
to ○ aPTT is more reliable than PTT because we add activator on
that component so that there would be a narrow reference
range → more reliable when it comes to the detection of
hemophilia
○ aPTT is prolonged for patient with hemophilia
● Increase metabolic state will increase factor requirements
○ Promotion of rest → decrease in metabolic rate → decrease
in clotting factor requirements
○ Limit activities specially contact sports or competitive sports
that would lead to injury
○ Activities are encouraged but not contact sports or
competitive sports
● Factor coverage for invasive procedures
○ Invasive procedures may result to excessive bleeding
○ If the patient has surgeries or procedures, we really have to
plan carefully because we have to do prophylactic treatment
of recombinant factor infusion so that the patient would not
experience or will have a decrease risk of having a massive
bleeding
● Document infusion and response to tx
○ Because these medications are extraneous recombinant
factor so there is a chance that patient may be allergic to
them → monitor the patient for reactions
● Avoid taking temperatures rectally or giving suppositories
○ Might damage the rectal mucosa → bleeding
● Check BP by cuff as little as possible
○ Make sure it's not too tight because it might result to bruising
● Use only paper or silk tape for dressings
○ Tegaderm or tape used to secure IV site may cause abrasion
→ bleeding
● Perform mouth care w/ glycerin swab
○ The most appropriate for smaller kids is the use of toothies
because we are sure that these tootsies are gentle in the
gums
○ Ex. in the market, we check for soft bristle brush but when
we try, it’s still harsh in the gums → bleeding (massive for
hemophilic patients; it would stop for a moment and after
some time, it would bleed again profusely)
○ Instead of toothbrush, use toothies or glycerin swab
● Limit venipunctures
○ Schedule laboratory procedures wherein only one blood
extraction would be done instead of several extractions
○ As nurses, we make sure that lab exams are properly
scheduled
● Do NOT give aspirin
○ Aspirin is an anticoagulant → inhibit platelets aggregation →
prone to bleeding
NOTE: Platelet counts of patients with hemophilia are normal. The platelets
are not affected, only the clotting factors are. The best lab procedure to do is
the PTT or aPTT (more reliable)
NURSING CARE OF A CHILD WITH HEMATOLOGIC DISORDER PEDIA LEC
Ma’am Jaclyn Charmaine J. Magpantay, RN, MAN
● Bleeding time would be normal in patients with hemophilia because
Von Willebrand Disease platelets are not affected. In VW, platelets may be decreased (platelets
● It’s good to compare Hemophilia with this disease aggregation might be affected) → bleeding time might be prolonged
● An autosomal DOMINANT disorder (only one copy of mutated gene ● In aPTT (most reliable lab result for hemophilia), it is prolonged in
would be needed to have this disorder) patient with hemophilia and VW disease
● If one parent is affected, there’s 50% chance that offspring will have the ● In factor VIII, depending on the type, if it’s hemophilia A, it would be
disease low. Normal for hemophilia B, but it’s low again in VW because in VW,
● Factor VIII will also be deficient plus platelets may or may not be factor VIII is also deficient
affected ● Factor IX is low for hemophilia B and normal for Hemophilia A and VW
● low levels of von Willebrand factor ● VW factor is low for VW disease and normal for Hemophilia A & B
● Most common form of disorder is autosomal dominant trait
● Disease can occur in both males and females equally Dengue Hemorrhagic Fever
● Common in the Philippines
MANIFESTATIONS ● Affects the platelets
● Easy bruising ● Caused by Dengue virus transmitted by a vector mosquito (Aedes
● Epistaxis Aegypti)
● Other clinical manifestations include: ○ Can easily be distinguished from other mosquitoes due to
○ Gingival bleeding their tiger appearance (white stripes)
○ Ecchymosis ○ Patients can have manifestations 4-5 days after being bitten
○ Increased bleeding w/ lacerations or during surgery and ○ Not all Aedes Aegypti can transmit dengue, but it is a good
dental extractions vector (can also transmit Zika virus)
○ Menorrhagia (increased menstrual bleeding) ○ Bites in broad daylight but can also bite at night (esp. well-lit
■ Pregnant patients may undergo massive bleeding areas); low-lying mosquito
during delivery ○ To minimize DHF, we need to remove areas where water can
○ GI bleeding accumulate (tires, pots, vases) since they like to dwell on
dark areas & stagnant water
NOTE: Hemarthrosis is not common in Von Willebrand unlike hemophilia and
○ Dengue virus has 4 serotypes/strains
the reason is unknown
■ If you have been infected by one serotype, you
will be immune to that but not to the other three
TREATMENT
■ If get infected again by dengue, it will have a more
● Similar to hemophilia A
severe manifestation
● Restore clotting factor and prevent complications associated w/
■ Patient is more at risk to develop severe dengue
bleeding
or DHF the second time they are infected
○ Infusion of vWB (Von WilleBrand) protein concentrate
● Affects all ages mostly 10-15 years
○ DDAVP
DIAGNOSTIC TEST
■ Stimulate the endothelial cells to release clotting
●
factor VIII in the bloodstream; intranasal
● Tourniquet test using the BP cuff
○ Amicar
○ take the BP
■ In cases of inhibitor development due to
○ take average/midline of systolic and diastolic
prolonged used of recombinant factor infusion
○ rest
○ inflate sa makukuhang values
NURSING MANAGEMENT
○ leave for 5 minutes
● Similar to Hemophilia A
○ check if there are signs of petechiae
● PRICES - Protection, Rest, Ice, Compression, Elevation, Support
MANIFESTATIONS OF DENGUE FEVER
● Fever
Hemophilia A Hemophilia B VW disease ● Rash
● Muscle & joint pain
Bleeding time Normal Normal Prolonged
● Nausea & vomiting
Prothrombin Normal Normal Normal
Time NOTE: Dengue fever can progress to Dengue Hemorrhagic Fever because of
aPTT Prolonged Prolonged Prolonged capillary leak syndrome or plasma leakage wherein there’s increased
permeability of capillary so plasma will sip into the capillary causing
Factor VIII Low Normal Low or normal
accumulation of plasma in other areas of body (heart, lungs) →
Factor IX Normal Low Normal
hemoconcentration → if not addressed can lead to Dengue Shock Syndrome
VWF Normal Normal Low

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NURSING CARE OF A CHILD WITH HEMATOLOGIC DISORDER PEDIA LEC
Ma’am Jaclyn Charmaine J. Magpantay, RN, MAN
● Hemodynamic stability
● Normal Hct and WBC
○ Since it’s a viral infection, WBC is decreased but
during this phase WBC recovers

TREATMENT
● Supportive therapy
○ Nurses address the symptoms patient is experiencing
● IV Fluids
○ Dehydration due to plasma leakage → provide isotonic IV
fluids and sometimes colloids
○ Monitor patient because of increased risk for circulatory
SIGNS AND SYMPTOMS
NOTE: Signs and symptoms of DHF depends on which phase the patient is in overload due to plasma leakage
1. Febrile Phase ○ Plasma leakage can cause dehydration and circulatory
overload at the same time
● N/V ● Bone pain
● High grade fever (2-4 ○ DHF also called ● Monitor BP (narrowed pulse pressure)
days) breakbone fever ○ Patient may be experiencing internal hemorrhage or shock
● Severe headache because of the pain ○ Narrow pulse pressure: <20 mmHg → check if patient is
● Retro-orbital pain ● Maculopapular rash experiencing other symptoms of shock
● Joint pain (arthralgia) ○ Petechiae (bleeding or ● No aspirin for fever
● Muscle pain (myalgia) bursting within
○ Drug of choice for fever is paracetamol
capillary) or purpura
○ Aspirin is anticoagulant → increases risk for bleeding since
rash (sign of bleeding
under the skin, the platelets for patients with DHF are already low
palpable, elevated) ● Plasma expander and platelet concentrate (below 20,000)
○ Nursing responsibilities are the same with blood transfusion
■ Stay with the patient
■ Monitor VS every 15 mins, every 30 mins, and
every hour
■ Check for transfusion reactions
2. Critical Phase
○ We transfuse platelet concentrates when platelet value falls
● Most patients would recover but if patient doesn’t, they can
below 20,000
have plasma leakage (usually happens when fever subsides or
● Oxygen PRN
defervescence)
○ Administered if there are signs of shock or plasma leakage
● Begins after defervescence (24-48 hours)
has affected lungs (pleural effusion)
○ After 24-48 hrs of defervescence, patient may
● DAT (except dark colored food) - Diet As Tolerated
recover completely or progress to a more severe type
○ Dark colored foods may mask the internal bleeding
of dengue called DHF which would lead to plasma
○ Ex. Patient ate tocino/pusit → vomit is dark → we may not
leakage or capillary leak syndrome
recognize if it’s the food or blood
○ The exact mechanism of the increased permeability
● Best treatment is PREVENTION
of capillaries is not known, but it may be due to the
○ Instruct patients to remove stagnant water
reactions of the capillary walls to the enzymes
released by the virus
● Plasma leakage - severe dengue Leukemia (Blood Cancer)
● Cancer of blood-forming cells that usually involves bone marrow and
● Reappearance of fever (saddleback fever)
lymphatics
○ On and off fever
● There are many types but the most common in pediatrics: Acute
● Could lead to shock
Lymphocytic Leukemia (ALL) and Acute Myeloid Leukemia (AML)
NOTE: In capillary leak syndrome, only the plasma leaks out of the
capillary, the RBCs will stay in the capillary → plasma goes out to
ANATOMY & PHYSIOLOGY REVIEW
lungs, heart, peritoneal membrane causing accumulation of fluid in ● Stem cells gives rise to different blood components
these organs → pleural effusion, cardiac overload, ascites → end ● Before they become mature, stem cells produce the immature cells
result is hemoconcentration (high hematocrit, but capillaries are full ○ megakaryoblast (immature) → platelets (mature)
of RBCs) ○ erythroblasts → RBC
NOTE: In DHF, platelets are affected so patients also have ○ myeloblast (immature granulocyte) → eosinophil, basophil,
thrombocytopenia. The exact mechanism of this is also unknown, neutrophil, monocyte
but one explanation is the virus has high affinity to platelets → ■ In AML, there’s increased number of myeloblast in
attach to platelets and replicate there → platelets with virus attacks bloodstream (no mature granulocytes → no
normal platelets → death of platelets → drastic drop of platelets function)
○ Lymphoblast → lymphocyte
3. Convalescent Stage
● Patient is recovering

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NURSING CARE OF A CHILD WITH HEMATOLOGIC DISORDER
Ma’am Jaclyn Charmaine J. Magpantay, RN, MAN
■ Lymphocytes give rise to B lymphocytes (cells
that mature in bone marrow), T lymphocytes
(mature in thymus), and Natural Killer Cells
■ In ALL, they stay as lymphoblast and never
develop to B cells, T cells, and NK cells
■ Lymphoblast is immature and not able to carry its
function
Agranulocytes (affected in ALL)
● lymphocyte and monocyte
● Lymphocytes aka Agranulocytes (B lymphocytes, T lymphocytes,
NK cells) are important in fighting abnormal cells
○ When they detect an abnormal cell in bloodstream, these
mature cells release chemicals that cause cell death on
abnormal cells
○ After killing it, they will proceed to finding more abnormal
cells and completely remove them from the bloodstream
○ They can only function if they are mature
○ NK cells are important in detecting and fighting tumor or
cancer cells → since this is missing/deficient, it is easy for
cancer cells to proliferate in leukemia (ALL)
Granulocytes (affected in AML)
● Myeloblast will not develop into mature granulocytes (basophil,
eosinophil, neutrophil)
○ Basophils - largest granulocyte cells important in immune /
allergic reactions
■ These granules release histamine to counteract
effects of allergic reaction
○ Neutrophils - responsible for phagocytosis
■ When they detect a pathogen, they extend a part
of their cell to phagocyte the pathogen →
resolves invasion of pathogen
○ Eosinophils - responsible for parasitic infections,
inflammation
■ Through degranulation (release of granules), they
are able to kill the intestinal worm
Acute Lymphocytic Leukemia
● Involves lymphoblasts (immature lymphocytes)
○ Rapid proliferation of lymphoblasts (acute because they
rapidly multiply in bloodstream) → outnumber normal cells
(RBC, WBC, platelets) → bone marrow stops producing
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cells (it can’t differentiate mature & immature cells so it
thinks the body has enough cells)
● 2-6 years of age
○ Toddlers & preschoolers
● Pancytopenia
○ Decrease in all blood components
○ Includes leukopenia, thrombocytopenia, & anemia
● Good prognosis; very responsive to treatment; high life expectancy
○ 80% of childhood leukemia is attributed to ALL, of this,
95% will have remission of s/sx (absent manifestations)
once chemotherapy is started
● Acute lymphocytic leukemia is the most common cancer in young
children
DIAGNOSIS
● CBC
○ All blood components are decreased
● Peripheral Blood Smear
○ Checking the number of a blood component in relation to
other blood components & morphology
○ Reveals a lot of “-blasts” or immature cells
● Bone Marrow biopsy
○ Reveals a lot of immature cells in the system but specifically
in the bone marrow
○ Normal site: iliac crest (based on book)
○ However, pediatricians often use sternum as site of
aspiration
■ Ideally should be on iliac crest so that it won’t be
traumatic on child bc in sternum they can see
what’s happening
○ Child is sedated
● Lumbar puncture
○ Aka lumbar tap or spinal tap
○ If suspected of CNS involvement
○ Patient in side-lying knee-chest position to widen the space
between the vertebrae
■ Easier to locate the site to aspirate CSF (between
L3 & L4)
■ Spinal cord ends at L2 and we don’t want to hit
the spinal cord when we aspirate CSF
■ Can also be L4 & L5 or L5 & S1 but L3 & L4 most
of the time
○ Side effect: spinal headache
■ Advise patient to remain flat and still to avoid
spinal leakage
SIGNS AND SYMPTOMS
● NOTE: S/sx are related to pancytopenia
● Normally, the first report of parents is on and off fever
● Extreme fatigue
● Headache
● Seizures
○ CNS involvement; a lot of immature cells in brain
NURSING CARE OF A CHILD WITH HEMATOLOGIC DISORDER
Ma’am Jaclyn Charmaine J. Magpantay, RN, MAN
● Frequent infections
● Anemia
● Bruising (ecchymosis) & bleeding
● Coughing & breathing difficulties
○ A lot of immature cells in lungs → may lead to fluid
accumulation in lungs → pleural effusion
● Lymphadenopathy (swelling of lymph nodes)
○ Lymph nodes are palpable for pediatric patients
● Swelling on different parts of the body
● Lack of appetite
● Stomachache
● Weight loss
● Joint swelling
● Bone and joint pain
● Skin rashes
NOTE: Lymphatics (lymphatic system) are greatly affected in ALL, rather than
the bone marrow → lymphadenopathy, swelling, bone & joint pain
MANAGEMENT
Chemotherapy
● End goal is to cure the patient meaning complete remission (free
from s/sx) for 5 consecutive years
● Initiated once leukemia is diagnosed
1. Induction Phase
○ Lasts for 4 weeks
○ Goal is to have remission or subside the manifestations
experienced by patient
○ Initiated as soon as patient is confirmed to have ALL
○ NR: Watch out for increased uric acid in bloodstream
■ Caused by the rapid death of leukemic cells
○ Patients may be receiving allopurinol
■ This decreases amount of uric acid in bloodstream
→ prevent accumulation of uric acids in kidney →
prevent kidney damage
■ Not an anti-gout for pediatric patients
■ For a patient to receive chemotherapy, they should
have good kidney function since chemotherapeutic
drugs are nephrotoxic
2. CNS Therapy or CNS Prophylactic Phase or Sanctuary Phase
○ Started once there is remission or improvement of condition
○ Administration of chemotherapy via intrathecal route (spinal
canal, subarachnoid space)
■ To make sure that brain is also free from leukemic
cells
○ Even if the patient doesn’t have manifestation because of
successful induction phase (95% of patients respond to
induction phase)
■ Cancer cells are deceiving so we have to make
sure that they are not present in other parts of the
body especially the brain
○ Usual drug: methotrexate
3. Consolidation Phase
○ 28 weeks of treatment
○ Eradication of leukemic cells that could still be present in the
bloodstream or any part of the body
○ To eradicate all stubborn leukemic cells that regrow or were
hidden and not targeted before
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○ Even if the patient is on remission, some leukemic cells may
be present and we would like to make sure they are gone in
the consolidation phase
4. Intensification Phase
○ Give another set of chemotherapeutic agents & we would
like to protect normal cells
○ Recovering medications are given to protect normal cells
from harsh effect of cytotoxic/chemotherapeutic agents
5. Maintenance Phase
○ Longest phase of chemotherapy
○ Making sure there’s no regrowth of leukemic cells and no
presence of leukemic cells in bloodstream
○ So that there’s no chance of relapse (reappearance of s/sx
that are already treated)
○ Complete eradication of leukemic cells
○ Complete remission for 5 consecutive years = patient is
considered cured
NOTE: Different books have different phases but it will always start with
induction phase and end with maintenance phase and end goal of
chemotherapy is CURE from cancer (5 consecutive years)
NOTE: For patients who have a relapse during the chemotherapy, they can be
a candidate for bone marrow transplant
NURSING CONSIDERATIONS
● Relieve pain
○ Because of lymphadenopathy, muscle and joint pain
○ Give tylenol, paracetamol, or acetaminophen
○ Avoid aspirin & NSAIDS (ideally, but no choice sometimes)
● Prevent infection
○ Patient already has pancytopenia + chemotherapeutic
drugs → more risk for infections
○ Implement reverse isolation (wear masks for both nurse &
patient, strict handwashing, limited visitors and no fresh
flowers)
○ If possible, only the nurse assigned to the patient should be
the nurse of the patient (not allowed to handle other
infectious patient)
■ Only patients receiving chemotherapy would be
our patients
■ We do not want to cause infection to our
immunocompromised patients
○ Neutropenic diet
■ No raw foods
■ Thoroughly wash vegetables for salads
■ Careful in sushi & raw steak
● Precaution in chemotherapy (N/V, anorexia, neuropathy, mucosal
ulceration, hemorrhagic cystitis, moon face, mood changes, alopecia)
○ N/V - Antiemetics are given most of the time
○ Anorexia - Small frequent feeding
○ Neuropathy - Encourage ambulation
NURSING CARE OF A CHILD WITH HEMATOLOGIC DISORDER PEDIA LEC
Ma’am Jaclyn Charmaine J. Magpantay, RN, MAN
○ Alopecia - Common concern of patients is if alopecia is ○ Ideally, after the patient responds well to induction phase &
permanent (no, it is temporary) there is remission of the manifestation → bone marrow
■ Because it targets rapidly dividing cells (such as transplant should follow so no maintenance phase to
hair follicles) patient with AML
■ Nurses should emphasize that it is temporary &
hair will regrow after stopping chemotherapy
once they have complete remission

Acute Myeloid Leukemia

● Granulocytes are affected
○ They remain as myeloblasts (bigger than lymphoblasts)
● Only 20% of childhood leukemias
○ Most of patients affected by AML are adults or adolescents
● Poor prognosis; life expectancy is 5-10 years (based on research)

● Punnett square - shows the percentage or the possibility that the

DIFFERENCE BETWEEN ALL AND AML person with hemophilia will have offsprings with hemophilia
● Examples:
AML ALL A male adolescent with hemophilia asks you what’s the percentage that he
Age Common adult Children will transfer it to this son
● He will only transfer it to his daughters (they will be carriers)
Lymphadenopathy Less common More common
Can a female with hemophilia transfer it to her sons?
Hepatosplenomegaly Less common More common ● Yes
● 25% if 4 children
Bone and joint pain Less common More common
● 50%
Gum hypertrophy More common Less common Can a female with hemophilia transfer it to her CHILDREN?
Blast cells Myeloblast Lymphoblast ● Yes. 25% (1 out of 4 children)

● The manifestation of ALL and AML are the same (attributed to Can a female with hemophilia transfer it to her SON?
pancytopenia of the patient) ● Yes. 50% because one of the 2 son’s chromosome will be affected
● But since ALL involves the lymphatics, there’s more incidence of
lymphadenopathy and bone and muscle joint pain
● With AML, since what’s greatly affected is the bone marrow, and the
occurrence of lymphadenopathies is decreased and not the common
compared to ALL
● According to age, ALL are common among children while AML is more
common in adults or in adolescents
● Hepatosplenomegaly is less common in AML because of the
involvement of the lymphatics. When there is an involvement of the
lymphatics in ALL, hepatosplenomegaly is more common to them and
because of hepatosplenomegaly in patient will ALL, they have this loss
of appetite (anorexia)
● Gum hypertrophy is more common in AML because the bone marrow is
affected. When there is bone marrow hyperactivity or increased
stimulation of the bone marrow, the bones (esp. facial bones) are
affected → gum hypertrophy
● The cells that are rampant or increase in AML would be myeloblast or
the myeloid while in ALL the increase would be lymphoblast

TREATMENT
● Chemotherapy
○ In ALL, there are different phases of chemotherapy:
induction, consolidation, and maintenance
○ In AML, the chemotherapy starts in induction phase but
there is no maintenance phase
■ Once there is remission after the induction phase,
→ proceed with bone marrow transplant ideally
so that complete remission could happen → life
expectancy will increase and the prognosis would
be good
● Bone marrow transplant

8 SACRAMENTO | SANTOS, C. | SANTOS, Z | SAPALO | SAUL | SERRANO| SUMABAT