NS2P1 Peds Mod 6: Physical Regulation: Self-care deficits in the pediatric client affecting physical

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NS2P1 Peds Mod 6: Physical Regulation: Self-care deficits in the pediatric client affecting physical
2015-03-05 17:03:55
NS2 NS2P1 Peds Mod6 Leukemia

NS2P1 Peds Mod 6: Physical Regulation: Self-care deficits in the pediatric client affecting physical regulation and sexuality
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  1. **List the Major Causes of Accidents for the Following Ages
    • =>Infants
    • MVA (motor vehicle accidents)
    • Falls-changing tables, fall while mom went for a diaper
    • Asphyxiation-stick things in mouth..
    • Choking
    • -Don't let them go home without a carseat, as close to 1 year as possible, generally like 20 pounds because the avg newborn is around 8 pounds and they triple their weight by one year of age. Have car seat facing backwards as long as possible

    • =>Toddlers
    • Preventable accidents-leading cause of death in toddlers
    • MVA
    • Drowning
    • Falls
    • Aspirations
    • Ingestion- more common.
    • Electrical
    • -they walk into traffic, swimming pool & drown, no cognitive skills, tell family to lock up all cleaning products & meds in locked cabinets, draino-Esophageal strictures

    • =>Preschoolers
    • -Little more common sense
    • MVA-run over cars also.. don't allow them to ride bikes ..run overs. /:
    • Falls (falling out of windows)
    • Drowning
    • Ingestion-More common in toddler period

    • =>School age
    • MVA
    • Falls

    • =>Adolescents
    • -a full time job,
    • cigarette smoking-entry to high risk behavior- then start drinking, then ddrugs, then violence
    • MVA-Every city has cars, so leading cause of death
    • Violence-gang violence, violence depending on where you live, leading cause of death in a big city
    • Suicide
  2. **Safe And Dangerous Toys for Infants: =>DangerousMobiles over cribStuffed animals with removable parts=>SafeSoft stuffed animalsRattlesChewable items such as teething rings
    • =>Dangerous
    • Mobiles over crib
    • Stuffed animals with removable parts

    • =>Safe
    • Soft stuffed animals
    • Rattles
    • Chewable items such as teething rings
  3. **Safe And Dangerous Toys forToddler
    • =>Dangerous
    • Small items that can be broken off and aspirated
    • Objects that have sharp edges
    • Toys that are for older children
    • Small toys that can be placed in the mouth

    • =>Safe
    • Large blocks
    • Stuffed animals
    • Large tricycles
    • Child approved play houses, slides
  4. **Toys for School Aged
    • =>Safe
    • -Look at labeled toys for age groups! Buy them.
    • Appropriately sized bicycles
    • Always wear helmets for skateboarding and bicycling
    • Books
    • Metal cars
    • Legos-big legos so they can't be swallowed.
    • Puzzles
  5. **Accident Prevention for Infants
    Car seat facing back in back seat for 1st year or realistically 20 lbs

    Never leave unattended on anything elevated off floor; don't put babies in the middle of the bed

    Keep dangerous articles away

    -medications, cleaning products, matches,Lock all dangerous substances; Child safety latches and electrical plugs

    If child is up and about they require 2 adult eyes on them at all times.Keep them away from mactches! Catch on fire-leading cause..
  6. **Accident Prevention Toddlers and Pre-schoolers
    • Keep all meds and poisons locked away
    • Keep furniture away from the window
    • Car seats facing forward in the back seat
    • Constant observation
    • Age appropriate toys
    • Monitor when out of the house
  7. **Safety for School Age
    Bicycle and skateboard safety: appropriate sized bicycle for age. Seat belts

    Teaching how to behave when traffic is present: slow down at intersections when cars are coming

    Emphasize importance of safety

    No jumping out of trees

    Care when crossing street
  8. **Safety for Adolescents
    • Avoid high risk behavior
    • Drugs Alcohol Violence
    • Sex- they shouldn't have sex until they know the repercussions.
    • Car safety-seatbelts!
    • Avoid gang involvement

    Parents should know what their children are doing, who they are with, and when they will be home.
  9. **Lead Poisoning
    • Exposure or ingestion of lead based substances
    • -The pathway for exposure may be food, air or water, Lead dneters child through ingestion or inhalation; most common route is hand to mouth from contaminated objects such as loose paint chils, pottery, ceramic ware coupled with the inhalation of lead dust in the environment

    -When lead enters the body, it affects the erythrocytes, bones and teet, and organs includeing brain and Nervous system.

    -paint of the wall, mexico plates have lead (get in food), stained glass, uncured pottery (most common)

    -symptoms: developmentally delayed, deposited in brain,

    => Erythrocyte Protoporphyrin test: indicatior of anemia

    =>TX chelation therapy! Removes the lead from the soft tissues into the bones "edta + bal" (is a mainstream treatment used to treat poisoning from toxic levels of certain metals. Injections of ethylene diamine tetraacetic acid (EDTA) or other chemicals bind, or chelate, iron, lead, mercury, cadmium, zinc, and some other metals, which are then eliminated from the body.)

    The term “chelation” comes from the Greek word chele, which means “claw,” referring to the way the chemical grabs onto metals. - Therapy does not counteract any effects of the lead

    -Medications include: calcium disodium, edetate, succimer, British Anti-Lewisite (BAL)-IV/IM routes

    => Provide adequate hydration and monitor kidne function for nepphotoxicity

    =>Xray of bones with lead poisoning: pencil drawings
  10. **Iron Poisoning
    Iron used to be red in china, buy over the counter, soooo kids thought they were m&m's /:

    Iron Ingestion from MVI (Multivitamin)

    Notify ER and bring child in. Call poision control center and give them info of what they need to do

    Syrup of ipecac is no longer recommended. Because it makes them vomit all day.

    NOW: GIve them Activated charcoal, down an NG tube, binds with IRON.
  11. **Aspiriin & Tylenol Poisoning
    • =>Aspirin
    • -GI effects: N/V, and thirst from dehydrations
    • -CNS: Hyperpnea, confusion, tinnitus, seizures, coma, circulatory collapse
    • -Metabolic: diaphoresis, fever, hyponatremia, hypokalemia, dehydration, hypoglycemia, Causes Metabolic acidosis & has High mortality
    • Notify ER and bring child in
    • -activated charcoal to decreease absorption of salicylate 

    • =>Tylenol
    • Toxic dose is 150 mg/Kg or higher in children
    • Notify ER and bring child in
    • -First 2-4 hours: malaise, nausea, vomiting, sweating, pallor, weakness
    • Activated charcoal: as they immediately take it!
    • Take by mouth, or with NG tube.
    • Mucomyst: give them once it starts to metabolize (smells like rotten eggs
    • - binds with tylenol to avoid the liver)
    • -dilute in juice or soda b/c of offensive odorit eventually passes through them)

    -> Best thing: keep them away from medications
  12. **Communicable Disease & IZ Contradictions
    • Promote vaccination!
    • -60% of the children in California have the vaccinations they need at 2 years. That means that 40% don’t
    • -Refer to Immunization schedule: http://www.cdc.gov/vaccines/schedules/easy-to-read/child.html#print

    • =>Contraindications to IZ’s
    • Family member or client is immunocompromised
    • Child has fever or is obviously ill(Live vaccines)
  13. **Child Abuse and Neglect
    • =>Prevention:
    • Identify families at risk (Teen, Drug or alcohol use, Homeless)
    • Intervene to prevent
    • Healthy families program
    • Identifies families at risk and provides them with services needed.

    • =>If abuse is suspected
    • Report immediately
    • Social services will determine if the child is in imminent danger
    • -drug users just love drugs more than babies.
    • -we are mandated reporters.
  14. Leukemia –
    • cancer of the blood-forming tissues, and the most common form of childhood
    • cancer. Leukemia is an unrestricted proliferation of immature WBCs in the
    • blood-forming tissues of the body and a low leukocyte count. In all types of
    • Leukemia, the proliferating cells depress the production of formed elements of
    • the blood in bone marrow by competing for and depriving normal cells of the
    • essential nutrients for metabolism. Children with Leukemia will typically
    • present with several weeks of mild to moderate illness, an unusually long
    • lasting malaise; they’re just not getting better, ineffective/immature WBCs that
    • do not prevent against infection. The child will often present with high blast
    • cells, low platelets, bleeding, and infection.
  15. Acute Lymphoblastic Leukemia (ALL)
    The most common type of cancer in children and is a cancer of the blood and bone marrow that progresses rapidly and creates immature blood cells, rather than mature ones.

    Risk assessment: Standard (low) risk – children aged 1 to 9 years that have a WBC count of less than 50,000/μL at diagnosis.

    =>High risk – children younger than 1 or older than 9 that have a white count of 50,000 μL or more at diagnosis.

    =>Treatment Done in phases; Induction therapy 1st stage which achieves complete remission OR <5% leukemic cells in the bone marrow, 2nd CNS prophylactic therapy (methotrexate into spinal column) which prevents leukemic cells from invading the CNS, 3rd Consolidation/Intensification therapy, Consolidation begins when leukemia is in remission and eradicates residual leukemia cells, followed by delayed intensification, which prevents emergence of resistant leukemic clones (relapse); 4th Maintenance therapy, often given in lower doses to maintain the remission phase.

    • =>Prognosis
    • ALL cure: Low-Risk is 85% to 95%, Standard-Risk 65% to 85%, and High-Risk 60% to 65%
  16. Acute Myelogenous (non-lymphoid) Leukemia
    The second most common form of childhood leukemia, primarily a cancer of the bone marrow and lymph nodes and does not occur in stages. It is usually found throughout the body at the time of diagnosis and may invade organs.

    • =>Treatment
    • Chemotherapy 2 phases: 1st Induction given in cycles that usually last several days and are repeated every 4 weeks until the bone marrow is free of cancer cells, 2nd Intensification which begins after remission (no cancer cells found in the bone marrow) 1 to 2 rounds of chemotherapy are administered and a stem cell transplant is often recommended. Most children do not receive maintenance doses of chemotherapy. As with ALL CNS prophylactic therapy (methotrexate into spinal column) which prevents leukemic cells from invading the CNS is given.

    • =>Prognosis
    • AML cure rate is 75% to 85% at the end of induction treatment. Refractory or recurrent AML; if the child does not go into remission or has a relapse the outlook is very poor. For both ALL and AML early diagnosis and treatment increases the chance of survival .
  17. **Leukemia
    • The most common cause of death from pediatric cancers
    • -Leading solid tumore in ped patient population, brain tumor (we don't talk about brain tumors in this lecture)


    • Cancer cells infiltrate bone marrow. They suppress blood formation.
    • Child typically has several weeks of mild illness
    • They are just not getting better
    • WBC’s that are produced are ineffective. They don’t protect against infection.
    • Typically child will present with:High blast cells, Low platelets, Bleeding, Infection
    • -If your kid doesn't get better by a week, bring them in!

    • =>Treatment
    • At risk for bleeding and infection due to low platelets and don't make proper wbcs
    • Promote G&D (Growth and development)
    • Support parents and keep informed

    • =>Risk Assessment
    • -Standard (low) risk: Includes children aged 1 to 9 years who have a white blood cell count of less than 50,000/µL at diagnosis.

    • -High risk: Includes children younger than 1 year or older than 9 years and children who have a white blood cell count of 50,000/µL or more at diagnosis.
    • -normal white blood count: 5-10 thousand.

    => Treatment ALL

    • There are different types of treatment for childhood acute lymphoblastic leukemia (ALL).
    • Different types of treatment are available for children with acute lymphoblastic leukemia (ALL).
    • Some treatments are standard (aka the currently used treatment), and some are being tested in clinical trials. A treatment clinical trial is a research study meant to help improve current treatments or obtain information on new treatments for patients with cancer.
    • -basically for 80% children, they survive to cure (which is considered 4 years) and go on to be cancer freee

    When clinical trials show that a new treatment is better than the standard treatment, the new treatment may become the standard treatment.-
  18. **LEUKEMIA Treatment done in PHASES:
    • 1. Induction therapy: This is the first phase of treatment. Its purpose is to kill the leukemia cells in the blood and bone marrow. This puts the leukemia into remission.
    • -Take them into bone marrow aspiration, insert central line, evaluate bone barrow for what types of cells are proliferating and then give them a diagnosis
    • -purpose to kill leukemia cells which divide very rapidly
    • -To put leukemia into remission.
    • Typically start chemotherapy at night as kids sleep, FIRST we hydrate them so specific gravity less than 1.005 , give them antiemetic before chemo.

    • 2. Consolidation/intensification therapy: This is the second phase of therapy. It begins once the leukemia is in remission.
    • -The purpose of consolidation/intensification therapy is to kill any remaining leukemia cells that may not be active but could begin to regrow and cause a relapse.

    • 3.Maintenance therapy: This is the third phase of treatment.
    • -Its purpose is to kill any remaining leukemia cells that may regrow and cause a relapse. Often the cancer treatments are given in lower doses than those used for induction and consolidation/intensification therapy.
    • -one of the things that they do at vcmc, conscious sedation and intrathecal methotrexate into spinal column to prevent CNS b/c you kill bone barrow & leukemia in circuling bloodboth cerebral spine doesn't cross the barrier; do LP & put to prevent recurrent leukemia, going into the spine.
  19. **Leukemia & Chemotherapy:
    AML treatment will involve higher doses of chemotherapy b/c stronger form/variant of cancer over a shorter period of time

    • VS. ALL will involve the use of lower doses over a longer period of time.
    • -Children with Down Syndrom-vent septal defects, higher risk for developing leukemia.

    • =>What Types of Cells are killed?
    • While chemotherapy drugs kill cancer cells, they can also damage normal cells. This happens because they target cells that are growing quickly such as cancer cells.
    • "Like killing cancer with baseball bat"
    • -Bone marrow is constantly producing

    =>Chemo damages other body systems as well: But in the process they also damage other fast-growing cells. The lining of the mouth and intestines, hair, and blood cells all grow quickly and are likely to be damaged by chemotherapy. -what cells can your body make quickly? alimentary track, bone marrow-rbcs only last three months, so bone marrow constantly produce blood products, attacks the hair cells that's growing constantly so typically these kids have low plateltets.

    =>Risk Factors of Chemo: As a result, children being treated with chemotherapy may have a higher risk of infection (from low white blood cell counts), may bruise or bleed easily (from low blood platelets), and tire easily (from low red blood cell counts). -Suffer septicemia

    • =>More Side Effects Of Chemo: Other side effects of chemotherapy can include temporary hair loss, nausea, vomiting, diarrhea, mouth sores, and loss of appetite.
    • -chemo damages heart, liver, you're at higher risk for developming more cancer even if you beat the cancer (affects antibodies)
  20. **Tumor Lysis Syndrome":
    • Is a side effect of chemotherapy. When leukemia cells are killed, they break open and release their contents into the bloodstream. This can affect the kidneys, heart, and nervous system. Giving the child extra fluids or certain drugs that help rid the body of these toxins can prevent this problem.
    • -IV fluids bbefore chemotherapy, specific gravity of <1.005,
    • -toxins can clog up the kidneys
    • -damages the heart & heart failur
  21. **Organ Damage of Chemo
    Organs that could be damaged by chemotherapy include the kidneys, liver, testicles, ovaries, brain, heart, and lungs. With careful monitoring, such side effects are rare. -Ovaries: may not be able to have children.
  22. **At Risk for Other Cancers
    One of the most serious side effects of ALL treatment is the chance of the child's developing a second leukemia, usually AML. This risk must be balanced against the clear benefit of treating a life-threatening disease such as leukemia with chemotherapy.
  23. **Treatment of Children with AML: TWO PHASES:
    Treatment for children with AML has 2 phases: induction and intensification

    • =>Induction in AML
    • The combinations of drugs used to treat AML are different from those used for ALL. Treatment is given in cycles that usually last several days. The cycles are repeated every 4 weeks until the bone marrow appears to be free of cancer cells.

    =>Intensification: This phase begins after a remission when no more leukemia cells are seen in the bone marrow. Usually 1 or 2 rounds of chemotherapy are given, and the doctor may recommend a stem cell transplant. Most children with AML do not need maintenance chemotherapy
  24. **AML: Supportive Care
    An important aspect of treatment for AML is supportive care (nursing care, nutrition, antibiotic use, blood transfusions, etc.). With this supportive care, children will have a 75% to 85% rate of remission at the end of induction.

    • =>Prognosis for AML
    • Refractory or recurrent AML: The outlook for the child who doesn’t go into remission (refractory AML) or who relapses is very poor.

    • => Survival
    • The 5-year survival rate for ALL has greatly increased over time and is now nearly 85% thanks to advances in treatment. Five-year survival rates of children with AML have also increased over time to about 50%.

    • => Survival Based on Risk
    • The chance of being cured of low-risk ALL is 85% to 95%. For standard-risk it is 65% to 85% and for high-risk, about 60% to 65%.
    • It is Important to Diagnose the child early in the disease for best prognosis.
  25. Side effects of Chemo therapy
    Drugs used for treatment kill cancer cells, but also cause damage to normal healthy cells. All cells that have high growth rates are targeted (hair, lining of the mouth and intestines, and blood cells). Chemotherapy are at risk for developing infections, bleeding/hemorrhage/anemia, other side effect include nausea, vomiting, loss of appetite, mouth sores/GI irritation, hair loss, and pain. Long term damage can occur to the kidneys, liver, testicles, ovaries, brain, heart, and lungs; careful monitoring has decreased these long term complications.

    Tumor lysis syndrome occurs as a side effect of chemotherapy, when leukemia cells are killed they break open and release their contents into the blood stream. This lysis affects the kidneys, heart and nervous system, it is important to provide extra IV /oral fluids and certain medications to help rid the body of these toxins and prevent complications.

    As with all cancers if you develop ALL or AML you are at a higher risk for developing other types of cancer during your lifetime. One of the most serious side effects of ALL treatment is the chance of developing a secondary leukemia; most often AML. The risks must be carefully balanced against the clear benefit of treating a life threatening disease.
  26. Recall the incidence, types and nursing systems for the pediatric self-care agency for child abuse and health care workers responsibility in reporting in reporting child abuse.
    Prevention: identify families that are at risk (Teens, drug or alcohol abuse/use, and homeless), intervene to prevent abuse, refer to community agencies and healthy families programs to provide at risk families with assistance and tools to prevent abuse/neglect.

    If abuse is suspected the nurse should report it immediately, and social services will determine if the child is in danger and take action to stop the abuse.
  27. With input from self-care agency identify specific measures, which can be taken to prevent the following types of accidents
    1. Falls
    2. Burns
    3. Drowning
    4. Poisoning
    5. Suffocation
    6. Auto accidents
    7. Insertion and inhalation of foreign objects
    1. Falls - Use window guardrail and fasten securely, place gates at the top and bottom of stairs, keep doors locked and childproof door handles, remove unsecured scatter rugs, keep crib rails fully raised and mattresses in lowest position, supervise at playgrounds.

    2. Burns - Turn pot handles to back of stove, place appliances (coffee maker, toaster) towards back of counters, keep electrical sockets covered and wires hidden or out of reach, test water in bath before contact with the child, stress the danger of open flames and teach what “hot” means.

    3. Drowning – Supervise closely around any source of water regardless of the depth, keep bathroom doors closed and toilet lids down, place fence around swimming pools, teach water safety and swimming lessons.

    4. Poisoning - Place potentially toxic substances in locked cabinets, teach children to stay out of trash containers, do not call medication “candy” refer to it as “medicine”, keep medication, cleaning supplies, and poisons secure and out of child’s reach.

    5. Suffocation – Cut large chunks of meat into small bite sized pieces, avoid hard candy fruit with pits, gum, mints, nuts, popcorn, grapes, and marshmallows. Choose large toys with no small or removable pieces. Keep all cords out of child’s reach and remove drawstrings from clothing, do not allow to play around/in old refrigerators, toy boxes, chests, etc.

    6. Auto accidents - use federally approved child safety seats, supervise children when playing outside, do not allow child to play near the street or near/behind parked cars, lock doors or fences when not directly supervising children, obey ALL traffic safety laws when driving and be aware of others.

    7. Insertion and inhalation of foreign objects – Same as suffocation… also avoid walking running with objects in mouth (lollipops, toothpicks)
  28. Recall accidental, poisoning with the following substances, including treatment, prognosis, and nursing systems: 
    1. Lead
    2. Iron
    3. Aspirin
    4. Tylenol
    1. Lead – Common causes: nonintact lead-based paint and/or lead-contaminated bare soil in the yard. Lead is ingested or inhaled into the child’s body, inhalation usually occurs during renovation/remodeling, and ingestion occurs during day-to-day play and mouthing activities. Lead affects the renal, hematologic, and neurologic systems. Treatment of lead poisoning is Chelation therapy which is removal of lead from circulating blood, tissues, and organs. Prognosis of treatment: most pathophysiologic effects of lead are reversible, but there is long lasting effects/deficits to the CNS.

    2. Iron – Common causes: mineral supplements or vitamins containing iron, child ingests large amounts of iron. In the 1st stage iron affects the gastrointestinal system, 2nd stage latency, 3rd stage systemic toxicity (metabolic acidosis, fever, bleeding, shock, death may occur), 4th stage, hepatic injury, seizures, and coma. Treatement: emesis or lavage, activated charcoal, and chelation therapy.

    3. Aspirin – Common causes: acute ingestion or chronic ingestion. Aspirin poisoning causes nausea, vomiting, disorientation, dehydration, tinnitus, coma, and convulsions. Treatment of aspirin poisoning is hospitalization, emesis, lavage, activated charcoal, and sodium bicarbonate.

    4. Tylenol – Common causes: acute ingestion. Tylenol affects the GI tract (nausea/vomiting), and hepatic system (jaundice, coagulation abnormalities) and the CNS (confusion, stupor). Treatment: Antidote N-acetylcysteine (Mucomyst) given orally.