Nursing Care of the Child

with Hematologic or
Anemia
Dr.Raeda Amaireh
 Nursing Care of the Child with Hematologic or
immunologic Dysfunction.
Anemia:
A condition in which the number of BBCS and/or the
Hemoglobin (Hb) concentration is reduced below normal.
As a result of this decrease, the 02 carrying capacity of
blood is diminished, causing a reduction in 02 available to
the tissues.

-Classification: Anemia is classified to:

a) Etiologic or physiologic → manifested by RBCS or Hb
depletion.
b) Morphology → changes in RBCS size, shape and/or color.
-S and S: Immunologic Dysfunction
 
-S and S:
General'S and S→ muscle weakness, casy fatigability,
shortness of breath, frequent resting. poor sucking, pale
skin.

• CNS Sand S → Headache, đizziness, iritability, attention

span, Apothy, depression.
• Shock (blood loss anemia) → poor peripheral perfuston,
skin moist-and-cool, low B.p.↑ HR
Therapeutic Management:
treating the underlying cause and make up for any
deficiency of blood.
-Patients-with severe anemia → 02 supply, bed rest,
replacement of intravascular volume by I.V fluids.

-Prepare the child and family for laboratory tests (e.g,

explaining the importance of each test).

↓ 02 tissue needs → activities are planned to promote rest

but prevent boredom (e.g watching TV listening to music,
reading...).

-Prevent complication (e.g, v exposure to infectious agent

due to t susceptibility to infection).
Iron deficiency anemia:
Caused by inadequate supply of dietary iron.
Therapeutic Management:
• It focuses on increasing the amount of supplement iron the
child receives through diet. Iron fortified formula provides a
constant amount of iron for infants.
• Oral iron should be given between meals, citrus juice helps
in absorption of iron.
• If vomiting or diarrhea occurs, give iron with meals and the
dose reduced then gradually increased. Stool may turns to
tarry green color from iron supplement; parents should be
reassured about that.
• If iron to be given IM, inject deeply into a muscle mass and
do not massage after injection to minimize skin staining and
irritation, and no more than I ml should be given in one site.
Sickle cell anemia (CSA):
Is a group of diseases collectively termed
Hemoglobinopathies, in which normal adult Hb is partly or
completely replaced by abnormal sickle Hb.

-S and S:
chronic anemia (Hb 6-9 g/dl), susceptibility to sepsis, strok,
visual disturbances, hematuria, obstructive jaundice,
pneumonia, severe abdominal pain, painful swelling of
hands and feet's, painful joints, cardiomegaly, systolic
murmur, progressive failure, liver cirrhosis and seizures.
Mosby items and derived items ©
2009, 2005 by Mosby, Inc., an
affiliate of Elsevier Inc.
-Therapeutic Management:

• Bone marrow transplantation a possible cure for SCD.

Medical management directed to support symptomatic
treatment:

1- Bed rest to minimize energy expenditure and 02 use.

2- Hydration through oral and I.V fluids.
3- Electrolyte replacement.
4- Blood replacement to treat anemia and reduced
viscosity of the sickeld blood.
5- Analgesic for the severe pain.
6- Antibiotics to treat any infection (as oral Penicillin).
 7- Administration of pneumococcal and meningococcal
and hepatitis B vaccine.
8- Exchange transfusion which reduces the number of
sickle cells and slow down hypoxia, thrombosis, tissue
ischemia, and injury.
9- Splenectomy may be life saving measure.
10- Applying heat to the affected area with exercises
(passive range of motion) is beneficial to promote
circulation and decrease pain.
11- Measuring I/O and V/S.
12- Child's weight should be taken as a baseline for
hydration, and abd-circumference to detect splenomegaly.
B- Thalassemia (Cooley anemia):
It's applied to a variety of inherited blood disorders
characterized by deficiencies in rate of production of
specific globin chain in Hb, which results in severe
anemia that would lead to cardiac failure and death in
early childhood without transfusion support.
S and S:
• Anemia, unexplained fever, poor feeding, greatly
enlarged spleen.
• With progressive anemia -> signs of chronic hypoxia,
bone pain, exercise tolerance, anorexia.
• Other features - small stature.
• Bone changes -> enlarged head, prominent frontal and
parietal bosses, flat or depressed bridge of the nose,
enlarged maxilla, protrusion of lip and upper central
incisors, oriental appearance of eyes.
-Therapeutic Management: Objective of therapy is to
(1) maintain sufficient Hb level,
(2) To prevent bone marrow expansion and the resulting
bony deformities.
(3) To provide sufficient RBC's to support gth and physical
activities. Transfusion are the foundation of medical
management, to maintain Hb level above 10g/dL, a
goal may require transfusion every 3 weeks.

The goal of this therapy:

(4) To improve physical and psychological well-being.
(5) ↓Cardiomegaly and hepato splenomegaly.
(6) Fewer bone changes.
(7) Near-normal gth and development.
(8) Fewer infection.
One of the complications of frequent blood transfusion is
iron over load, to minimize the hemosiderosis
Defroxarmine (Desferal) an iron - chelating agent is given
with small oral supplement of vitamin C.

-Splenectomy may require, and the major complication

from splenectomy is infections.

-Bone marrow transplantation is a treatment for some

children.
A plastic Anemia:
A condition in which all formed elements of the blood is
simultaneously depressed. It can be primary (congenital) or
secondary (acquired → infection of human parvovirus,
hepatitis, drugs and chemotherapy ... etc.

-Therapeutic Management:
Immunosuppressive therapy to remove presumed
immunologic functions that prolong aplasia.
• Bone marrow transplant.
• the care of the child with a plastic anemia is the same as
child with leukemia.
Hemophilia
Refers to a group of bleeding disorders in which there
is deficiency of one of the factor Hemophilia: necessary
for coagulation of the blood (Factor VIII deficiency).

-S and.S:
• Prolonged bleeding anywhere in the body.
• Hemorrhage from any trauma.
• Excessive bruising.
•Hematoma, spontaneous hematuria.
-Therapeutic Management:
• Replacement of the missing clotting factor.
• Non steroidal anti-inflammatory drugs (Ibuprofen) to relieve
pain.
• Prevent bleeding appropriate exercises and activities, safe
environment.
• For mouth care use sponge-tipped disposable tooth brush
or soften the tooth brush with warm water.
• SC injections are substitute for IM injection whenever
possible.
• Recognize and control bleeding RICE → Rest, Ice,
Compression and Elevation.
• Support family and prepare for home care.
Idiopathic Thrombocytopenic purpura (ITP):

Is an acquired hemorrhagic disorder characterized

by:

(1) Thrombocytopenia Excessive destruction of

platelets.
(2) (2) Purpura → Discoloration caused by petechiae
beneath the skin.
The disease occurs in two forms; acute (self-limiting) or
chronic (greater than 6 months duration).
In ITP platelets count is reduced to below 20.000 mm'.
-S and S:
Easy bruising, petechiae, bleeding from mucus
membranes, epistaxis, internal hemorrhage (evidence by,
melena, hematuria).

Therapeutic Management:
- It's primary supportive, since the disease is self-limited in
the majority of cases.
-Treatment for acute presentation is symptomatic by giving
prednisone, I.V immunoglobulin, anti - D antibody.
 -Splenectomy is generally recommended to wait until
child is more than 5 years of age because of increased
bacterial infection.
-Pneumococcal and meningococcal vaccines to be
given before splenectomy, in addition to prophylaxis
penicillin after splenectomy.

leukemia's:
Cancer of blood- forming tissues, is the most common
form of childhood cancer.
• Leukemia is abroad term given to a group of
malignant diseases of bone marrow and lymphatic
system.
• Leukemia is an unrestricted proliferation of
immature WBC's in the blood- forming tissues of the
body.
There are three consequences S and S:
1- Anemia - ↓RBC
2- Infection → neutropenia.
3- Bleeding tendency →↓platelets production.
Pallor, fatigue, pain, hemorrhage, splenomegaly, vomiting,
severe headache, muscle wasting, wt loss, Anorexia, fever,
tendency toward fractures.
-Therapeutic management:
It involves the use of chemotherapy in 4 phases
1. Induction therapy which achieves a complete remission
or less than 5% leukemia cells in the bone marrow.
2. CNS prophylactic therapy which prevents leukemia cells
from invading the CNS
3. intensification therapy (consolidation)→which eradicates
residual leukemia cells.
4. Maintenance therapy → which serves to maintain the
remission phase.
Nursing considerations:
• Prepare the child and family for diagnostic and
therapeutic procedure:
• Children must undergo several tests as lumber puncture,
blood tests .etc, therefore
• child needs explanation for each procedure and what can
be expected.
Relieve pain:
Dosage of opioids (narcotics) is adjusted to be
administered around the clock for optimal pain control

Prevent complications of myelosuppression:

infection → the child is susceptible to
infection during 3 phases:
1- At time of diagnosis.
2- During immunosuppressive therapy.
3- After prolonged antibiotics. Prevention by: strict hand
washing,

private room, strict visitors, blood, urine, stool,

nasopharyngeal cultures are taken, chest x- ray.

Hemorrhage → observes for bleeding everywhere in the

body. Avoid rectal temp,observe for venipuncture sites and
IM injections, platelets are administered.

-Anemia → by blood trans fusion.

• Use precautions in administering and handling
chemotherapeutic agents: Venous access devices
facilitate I.V administration of the drug.
-management of drug toxicity
Nausea and vomiting →give antiemetic before the
chemotherapy begin
Anorexia → NGT feeding or TPN may be implemented for
children with significant nutritional problems.

-Mucosal ulceration → provides moist, soft diet appropriate

to child's age and references.

• Use a soft sponge tooth brush. Frequent mouth washes

with normal saline.
• Use local anesthesia. for stomatitis. Give pain control. TPN
may be necessary.
• For rectal ulceration use-ointment and dressing and avoid
rectal temp.

-Neuropathy → gives laxatives. Ambulate the child cautiously.

Provide soft liquid diet for jaw pain.
• Hemorrhagic cystitis → fluid intake, frequent voiding.

• Alopecia → use soft cotton cap, hair regrows in 3-6 mon

and may be different in color and texture.

* Provide continuous physical care and emotional support.

Because of the improved survival of these children
continued monitoring physical and intellectual gth and
development is essential. Nurse should stress on the
importance of regular follow up.
Lymphomas:

-Hodgkin Disease:
Is a neoplastic disease that originates in the lymphoid
system and primarily involves the lymph nodes. It's
prevalent in adolescence and young adults (15-19 yrs).

-S and S:
Painless enlargement of lymph nodes especially cervical
area, non productive cough, abdominal pain, low grade
fever, anorexia, nausea, wt. loss, night sweats, pruritus.
-Therapeutic Management:

• Radiation and chemotherapy.

• Children with splenectomy antibiotics and

immunization against pneumococci and
meningococcal are recommended.
-Nursing consideration:
Involves the same objectives for patients with other types of
cancer, especially, preparation for diagnostic procedures and
operations, explanation of treatment and side effects, child
and family support.
Non-Hodgkin lymphoma (NHL):
• 60% of pediatric lymphoma is NHL (children under 15 years
of age).
-Therapeutic Management:
• Chemotherapy and radiation.
• Nursing care the same as child with leukemia. Human
immunodeficiency virus (HIV) infection and Acquired
immunodeficiency syndrome (AIDS):
HIV is transmitted through sexual contacts on parental
exposure to blood or body fluids containing visible blood.
Infected pregnant woman passes the infection to her infant.
 -S and S:
Lymphadenopathy, hepatosplenomegaly., oral candidiasis,
chronic or recurrent diarrhea, failure to thrive,
developmental delay, parotitis.

Therapeutic Management and nursing consideration:

The goals for HIV infection includes:
• Slowing gth of virus.
• preventing and treating opportunistic infections.
• providing nutritional support.
• Symptomatic treatment.
• Education concerning transmission and control of
infectious diseases is essential for the child and anyone
involved in their care.
• Aggressive pain management is essential.
 Blood transfusion:
Administration of blood component needed as packed RBC's in
anemia, platelets for bleeding
General guide lines that apply to all transfusion:
• Take V/S before and after administering of transfusion and every 15
miñ for 1 hr.
• Check recipient with the donor's blood group and type.
• Administer the first 50 ml of blood or 20% of the volume slowly and
stay with the child.
• Administer with normal saline.
• Administer blood through appropriate filler to eliminate particles in
the blood.
• Use the blood within 30 min of its arrival.
• Infuse unit of blood within 4 hrs.
• If a reaction of any type is suspected; take V/S , stop
the transfusion, maintain patent I.V line with normal
saline and use new tube, and do not restart the
transfusion until the child's condition has been
evaluated.

-Blood is usually administered to children by infusion

pump, regular drops usually 10-15 drops/ml.

-Major hazards of transfusion: See table (26-6).

 table (26-6).

PRECAUTIONS/NURSING
IMPLICATION SICNS/SYMPTOMS RESPONSIBILITIES

hemolytic Chills Identify donor and recipient

reactions last Shaking blood types and groups
severe type, before trans- fusion is
but rare begun; verify with another
nurse or practitioner
 table (26-6).

PRECAUTIONS/NURSING
AIPLICATION SICNS/SYMPTOMS RESPONSIBILITIES

incompatible blood Fever Transfuse blood slowly for

Pain at needle site first 15-20 minutes and/or
and along venous initial 20% of blood
tract volume; remain with
patient
Stop transfusion
immediately in event of
signs or symptoms,
maintain patent
intravenous line,
 table (26-6).

PRECAUTIONS/NURSING
AIPLICATION SICNS/SYMPTOMS RESPONSIBILITIES

and notify practitioner

Incompatibility in Nausea/vomiting
multiple Sensation of Save donor blood to re-cross match
transfusions tightness in with patient's blood

chest Monitor for evidence of shock

Insert urinary catheter and
Red or black urine monitor hourly outputs
Send sample off patient's blood
headache and urine to laboratory for
presence-of hemoglobin (ındicates
Flank pain intravascular hemolysis)
Progressive signs of Observe for signs of hemorrhage
shock resulting from disseminated
and/or renal failure intravascular coagulation (DIC)
Support medical therapies-to
reverse shock
 table (26-6).

PRECAUTIONS/NURSING
AIPLICATION SICNS/SYMPTOMS RESPONSIBILITIES

febrile reactions Fever May give acetaminophen for

Leukocyte or prophylaxis Leukocyte poor red
chills
platelet. blood cells (RBC) are
less likely
antibodies
to cause reaction

Plasma protein Stop transfusion immediately,

antibodies report to practitioner for
evaluation
 table (26-6).

PRECAUTIONS/NURSING
AIPLICATION SICNS/SYMPTOMS RESPONSIBILITIES

allergic reactions Urticaria Give antihistamines for

Recipient reacts to Flushing prophylaxis to children with
allergens in donor's Asthmatic wheezing tendency to- ward allergic
blood reactions Stop transfusions
Laryngeal edema immediately Administer
epinephrine for wheezing or
anaphylactic reaction
 table (26-6).

PRECAUTIONS/NURSING
AIPLICATION SICNS/SYMPTOMS RESPONSIBILITIES

circulatory transfuse blood slowly

Precordial pain
overload Prevent overload by using
packed RBCS or
Dyspnea
Too rapid administering divided
transfusion (even amounts of blood
Rales
a small quantity)
 table (26-6).

PRECAUTIONS/NURSING
AIPLICATION SICNS/SYMPTOMS RESPONSIBILITIES

Excessive quantity Cyanosis Use infusion pump to regulate

of blood Dry cough and maintain flow rate
transfused (even Distended neck veins
slowly) Stop transfusion immediately
if signs of overload

Place child upright with feet in

dependent position to
increase venous resistançe
 table (26-6).

PRECAUTIONS/NURSING
AIPLICATION SICNS/SYMPTOMS RESPONSIBILITIES

air emboli Sudden difficulty Normalize pressure before

in container is empty when
May occur when infusing blood under pressure
blood breathing

transfused under
Sharp pain in chest
-pressure Clear tubing of air by
Apprehension
aspirating air with syringe at
nearest Y connect or if air is
observed in tubing;
disconnect tubing and allow
blood to flow until air has
escaped only if a Y connector
is not available
 table (26-6).

PRECAUTIONS/NURSING
AIPLICATION SICNS/SYMPTOMS RESPONSIBILITIES

Hypothermia Chi is: Allow blood to warm at room

Low temperature temperature (less than 1 hour)
Irregular heart rate Use approved mechanical
Possible cardiac blood warmer or electric
arrest warming coil to warm blood
rapidly; never use microwave
oven
Take temperature if patient
complains of chills; if
subnormal, stop transfusion
 table (26-6).

PRECAUTIONS/NURSING
AIPLICATION SICNS/SYMPTOMS RESPONSIBILITIES

Nausea, diarrhea
Electrolyte Use washed RBCS or fresh
Muscular weakness
disturbances blood if patient is at risk
Flaccid paralysis
Hyperkalemia (in
Paresthesia of
massive
extremities
transfusions or in
Bradycardia
patients with renal
Apprehension
problems)
Cardiac arrest